attached
Select one of the cases below and answer the corresponding questions. Make sure to identify which case you have selected in the heading of your post e.g., Case #1.
The Discussions will be graded as follows:
· Fully and correctly answered each question– 4pts
· Made reference to assigned reading when answering the question (e.g., according to Corey…..)- 1pt
· One outside resource was consulted on one of the issues discussed in the response. Make sure to refer to the source in your response and cite reference at the end of your post in APA format (e.g., according to a recent article in ……., anxiety with children is common….(Silverman, 2002)- 2 pts
· Responded to at least 2 other student’s posts-1 pt
Case #1: A client who has not questioned her religious beliefs
Brenda, age 22, comes to see you because of problems in living at home with her family. She tells you that she feels dependent both financially and emotionally on her parents and that although she would like to move out and live with a girlfriend, she has many fears of taking this step. She also says that her religion is extremely important to her and that she feels a great deal of guilt over the conflict she has with her parents. After some discussion you find that she has never really questioned her religious values and that it appears that she has completely accepted the beliefs of her parents. Brenda says that if she followed her religion more closely, she would not be having all these difficulties with her folks. She is coming to you because she would “like to feel more like an independent adult who could feel free enough to make my own decisions.”
1. Which personal characteristics of effective counselors from Ch. 2 would be most helpful in this situation (at least 2) and why?
2. Which of the issues faced by beginning therapists from Ch. 2 might become an issue for you in this specific case (at least 2 issues) and why?
3. What counseling ethical issues from Ch. 3 do you need to consider in this specific case (at least 2) and why?
Case # 2: A woman struggling over an abortion decision
This case involves Melinda, a 25-year-old Latina who says she wants to have an abortion. She has been married for three years, already has two children, and says: “We had to get married because I was pregnant. We didn’t have money then. The second kid was not planned either. But now we really can’t afford another child.” Her husband is a policeman going to law school at night. She works as a housekeeper and plans to return to school once her husband finishes his studies and it is “her turn.” He should graduate in another year, at which time she is scheduled to enroll in classes at the community college. Having another baby at this time would seriously hamper those arrangements in addition to imposing the previously mentioned financial burden. But the client reports:
“I go to call the clinic, and I just can’t seem to talk. I hang up the minute they answer. I just can’t seem to make the appointment for the abortion, let alone have one. I was never much of a Catholic, and I always thought you should be able to get an abortion if you wanted one. What’s wrong with me? And what am I going to do? I don’t exactly have a lot of time.”
1. Which personal characteristics of effective counselors from Ch. 2 would be most helpful in this situation (at least two) and why?
2. Which of the issues faced by beginning therapists from Ch. 2 might become an issue for you in this specific case (at least 2 issues) and why?
3. What counseling ethical issues from Ch. 3 do you need to consider in this specific case (at least 2) and why?
Case #3: A woman who wants her marriage and her affair
Loretta and Bart come to you for marriage counseling. In the first session, you see them as a couple. Loretta says that she can’t keep going on the way they have been for the past several years. She tells you that she would very much like to work out a new relationship with him. He says that he does not want a divorce and is willing to give counseling his “best shot.” Loretta comes to the following session alone because Bart had to work overtime. She tells you that she has been having an affair for two years and hasn’t yet mustered up the courage to leave Bart for this other man, who is single and is pressuring her to make a decision. She relates that she feels very discouraged about the possibility of anything changing for the better in her marriage. She would, however, like to come in for some sessions with Bart because she doesn’t want to hurt him.
1. Which personal characteristics of effective counselors from Ch. 2 would be most helpful in this situation (at least 2) and why?
2. Which of the issues faced by beginning therapists from Ch. 2 might become an issue for you in this specific case (at least 2 issues) and why?
3. What counseling ethical issues from Ch. 3 do you need to consider in this specific case (at least 2) and why?
63727_fm_rev02.indd 6 18/09/15 11:54 AM
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Theories at-a-Glance
The tables in this book compare theories over a range of topics, thereby providing you with
the ability to easily compare, contrast, and grasp the practical aspects of each theory. These
tables also serve as invaluable resources that can be used to review the key concepts, philoso-
phies, limitations, contributions to multicultural counseling, applications, techniques, and
goals of all theories in this text.
The following chart provides a convenient guide to the tables in this text.
Pages
6 –7 Table 1.1 Overview of Contemporary Counseling Models
62– 63 Table 4.1 Ego-Defense Mechanisms
65– 66 Table 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s
Psychosocial Stages
432 Table 15.1 The Basic Philosophies
433– 434 Table 15.2 Key Concepts
438 Table 15.3 Goals of Therapy
441– 442 Table 15.4 The Therapeutic Relationship
443– 444 Table 15.5 Techniques of Therapy
444– 445 Table 15.6 Applications of the Approaches
446 Table 15.7 Contributions to Multicultural Counseling
447 Table 15.8 Limitations in Multicultural Counseling
448– 449 Table 15.9 Contributions of the Approaches
449– 450 Table 15.10 Limitations of the Approaches
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Overview of Focus Questions for the Theories
For the chapters dealing with the different theories, you will have a basic understand-
ing of this book if you can answer the following questions as they apply to each of the eleven
theories:
Who are the key figures (founder or founders) associated with the approach?
What are some of the basic assumptions underlying this approach?
What are a few of the key concepts that are essential to this theory?
What do you consider to be the most important goals of this therapy?
What is the role the therapeutic relationship plays in terms of therapy outcomes?
What are a few of the techniques from this therapy model that you would want to incorporate
into your counseling practice?
What are some of the ways that this theory is applied to client populations, settings, and treat-
ment of problems?
What do you see as the major strength of this theory from a diversity perspective?
What do you see as the major shortcoming of this theory from a diversity perspective?
What do you consider to be the most significant contribution of this approach?
What do you consider to be the most significant limitation of this approach?
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Australia • Brazil • Mexico • Singapore • United Kingdom • United States
Gerald Corey
California State University, Fullerton
Diplomate in Counseling Psychology,
American Board of Professional Psychology
Theory and PracTice
of counseling and
PsychoTheraPy
Tenth Edition
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some third party content may be suppressed. Editorial review has deemed that any suppressed
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Printed in the United States of America
Print Number: 01 Print Year: 2015
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ALL RIGHTS RESERVED. No part of this work covered by the copyright
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the publisher.
Theory and Practice of Counseling and
Psychotherapy, Tenth Edition
Gerald Corey
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WCN: 02-200-203
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To the founders and key figures of the theories presented
in this book—with appreciation for their contributions
to contemporary counseling practice.
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iv
abouT The auThor
gerald corey is Professor Emeritus of Human Services and Counseling at
California State University at Fullerton. He received his doctorate in counseling
from the University of Southern California. He is a Diplomate in Counseling Psy-
chology, American Board of Professional Psychology; a licensed psychologist; and a
National Certified Counselor. He is a Fellow of the American Psychological Associa-
tion (Division 17, Counseling Psychology; and Division 49, Group Psychotherapy);
a Fellow of the American Counseling Association; and a Fellow of the Association
for Specialists in Group Work. He also holds memberships in the American Group
Psychotherapy Association; the American Mental Health Counselors Association;
the Association for Spiritual, Ethical, and Religious Values in Counseling; the Asso-
ciation for Counselor Education and Supervision; and the Western Association of
Counselor Education and Supervision. Both Jerry and Marianne Corey received the
Lifetime Achievement Award from the American Mental Health Counselors Associ-
ation in 2011, and both of them received the Eminent Career Award from ASGW in
2001. Jerry was given the Outstanding Professor of the Year Award from California
State University at Fullerton in 1991. He regularly teaches both undergraduate and
graduate courses in group counseling and ethics in counseling. He is the author or
coauthor of 15 textbooks in counseling currently in print, along with more than 60
journal articles and book chapters. Several of his books have been translated into
other languages. Theory and Practice of Counseling and Psychotherapy has been trans-
lated into Arabic, Indonesian, Portuguese, Turkish, Korean, and Chinese. Theory and
Practice of Group Counseling has been translated into Korean, Chinese, Spanish, and
Russian. Issues and Ethics in the Helping Professions has been translated into Korean,
Japanese, and Chinese.
In the past 40 years Jerry and Marianne Corey have conducted group counsel-
ing training workshops for mental health professionals at many universities in the
United States as well as in Canada, Mexico, China, Hong Kong, Korea, Germany,
Belgium, Scotland, England, and Ireland. In his leisure time, Jerry likes to travel,
hike and bicycle in the mountains, and drive his 1931 Model A Ford. Marianne
and Jerry have been married since 1964. They have two adult daughters, Heidi and
Cindy, two granddaughters (Kyla and Keegan), and one grandson (Corey).
Recent publications by Jerry Corey, all with Cengage Learning, include:
�� Theory and Practice of Group Counseling, Ninth Edition (and Student Manual)
(2016)
�� Becoming a Helper, Seventh Edition (2016, with Marianne Schneider
Corey)
�� Issues and Ethics in the Helping Professions, Ninth Edition (2015, with Mari-
anne Schneider Corey, Cindy Corey, and Patrick Callanan)
�� Group Techniques, Fourth Edition (2015, with Marianne Schneider
Corey, Patrick Callanan, and J. Michael Russell)
�� Groups: Process and Practice, Ninth Edition (2014, with Marianne Schnei-
der Corey and Cindy Corey)
iv
63727_fm_rev02.indd 4 18/09/15 11:54 AM
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v
�� I Never Knew I Had a Choice, Tenth Edition (2014, with Marianne Schneider
Corey)
�� Case Approach to Counseling and Psychotherapy, Eighth Edition (2013)
�� The Art of Integrative Counseling, Third Edition (2013)
Jerry Corey is coauthor (with Barbara Herlihy) of Boundary Issues in Counseling:
Multiple Roles and Responsibilities, Third Edition (2015) and ACA Ethical Standards Case-
book, Seventh Edition (2015); he is coauthor (with Robert Haynes, Patrice Moulton,
and Michelle Muratori) of Clinical Supervision in the Helping Professions: A Practical
Guide, Second Edition (2010); he is the author of Creating Your Professional Path: Les-
sons From My Journey (2010). All four of these books are published by the American
Counseling Association.
He has also made several educational DVD programs on various aspects of
counseling practice: (1) Ethics in Action: DVD and Workbook (2015, with Marianne
Schneider Corey and Robert Haynes); (2) Groups in Action: Evolution and Challenges
DVD and Workbook (2014, with Marianne Schneider Corey and Robert Haynes);
(3) DVD for Theory and Practice of Counseling and Psychotherapy: The Case of Stan and
Lecturettes (2013); (4) DVD for Integrative Counseling: The Case of Ruth and Lecturettes (2013,
with Robert Haynes); and (5) DVD for Theory and Practice of Group Counseling (2012).
All of these programs are available through Cengage Learning.
63727_fm_rev02.indd 5 18/09/15 11:54 AM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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Preface xi
P A R T 1
BASIC ISSUES IN
COUNSELING PRACTICE
1 Introduction and Overview 1
introduction 2
Where I Stand 3
Suggestions for Using the Book 5
Overview of the Theory Chapters 6
Introduction to the Case of Stan 9
Introduction to the Case of Gwen 13
2 The Counselor: Person and
Professional 17
introduction 18
The Counselor as a Therapeutic Person 18
Personal Therapy for the Counselor 20
The Counselor’s Values and the Therapeutic Process 22
Becoming an Effective Multicultural Counselor 25
Issues Faced by Beginning Therapists 28
Summary 35
3 Ethical Issues in Counseling
Practice 37
introduction 38
Putting Clients’ Needs Before Your Own 38
Ethical Decision Making 39
The Right of Informed Consent 41
Dimensions of Confidentiality 42
Ethical Issues From a Multicultural Perspective 43
Ethical Issues in the Assessment Process 45
Ethical Aspects of Evidence-Based Practice 48
Managing Multiple Relationships in Counseling
Practice 49
Becoming an Ethical Counselor 52
Summary 53
Where to Go From Here 53
Recommended Supplementary Readings for
Part 1 54
P A R T 2
THEORIES AND TECHNIQUES
OF COUNSELING
4 Psychoanalytic Therapy 57
introduction 58
Key Concepts 59
The Therapeutic Process 66
Application: Therapeutic Techniques and
Procedures 72
Jung’s Perspective on the Development of
Personality 77
Contemporary Trends: Object-Relations
Theory, Self Psychology, and Relational
Psychoanalysis 79
Psychoanalytic Therapy From a Multicultural
Perspective 84
Psychoanalytic Therapy applied to the case of
stan 85
Psychoanalytic Therapy applied to the case of
gwen 87
Summary and Evaluation 89
Self-Reflection and Discussion Questions 92
Where to Go From Here 92
Recommended Supplementary Readings 93
5 Adlerian Therapy 95
introduction 98
Key Concepts 98
The Therapeutic Process 104
Application: Therapeutic Techniques and
Procedures 108
Adlerian Therapy From a Multicultural
Perspective 119
adlerian Therapy applied to the case of stan 121
adlerian Therapy applied to the case of gwen 122
Contents
vii
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viii C o n t e n t s
Summary and Evaluation 124
Self-Reflection and Discussion Questions 126
Where to Go From Here 127
Recommended Supplementary Readings 128
6 Existential Therapy 129
introduction 132
Key Concepts 137
The Therapeutic Process 146
Application: Therapeutic Techniques and
Procedures 149
Existential Therapy From a Multicultural
Perspective 153
existential Therapy applied to the case
of stan 155
existential Therapy applied to the case
of gwen 156
Summary and Evaluation 157
Self-Reflection and Discussion Questions 160
Where to Go From Here 160
Recommended Supplementary Readings 162
7 Person-Centered Therapy 163
introduction 165
Key Concepts 170
The Therapeutic Process 171
Application: Therapeutic Techniques and
Procedures 176
Person-Centered Expressive Arts
Therapy 180
Motivational Interviewing 182
Person-Centered Therapy From a Multicultural
Perspective 184
Person-centered Therapy applied to the case
of stan 186
Person-centered Therapy applied to the case
of gwen 187
Summary and Evaluation 190
Self-Reflection and Discussion Questions 193
Where to Go From Here 193
Recommended Supplementary Readings 195
8 Gestalt Therapy 197
introduction 199
Key Concepts 200
The Therapeutic Process 206
Application: Therapeutic Techniques and
Procedures 211
Gestalt Therapy From a Multicultural
Perspective 220
gestalt Therapy applied to the case of stan 221
gestalt Therapy applied to the case of gwen 223
Summary and Evaluation 224
Self-Reflection and Discussion Questions 227
Where to Go From Here 227
Recommended Supplementary Readings 229
9 Behavior Therapy 231
introduction 233
Key Concepts 236
The Therapeutic Process 238
Application: Therapeutic Techniques and
Procedures 240
Behavior Therapy From a Multicultural
Perspective 258
behavior Therapy applied to the case of stan 259
behavior Therapy applied to the case of gwen 260
Summary and Evaluation 262
Self-Reflection and Discussion Questions 265
Where to Go From Here 266
Recommended Supplementary Readings 267
10 Cognitive Behavior Therapy 269
introduction 270
Albert Ellis’s Rational Emotive Behavior
Therapy 270
Key Concepts 272
The Therapeutic Process 273
Application: Therapeutic Techniques and
Procedures 275
Aaron Beck’s Cognitive Therapy 281
Christine Padesky and Kathleen Mooney’s
Strengths-Based Cognitive Behavioral Therapy 289
Donald Meichenbaum’s Cognitive Behavior
Modification 293
Cognitive Behavior Therapy From a Multicultural
Perspective 298
cognitive behavior Therapy applied to the case
of stan 300
cognitive behavior Therapy applied to the case
of gwen 302
Summary and Evaluation 303
63727_fm_rev02.indd 8 18/09/15 11:54 AM
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C o n t e n t s ix
Self-Reflection and Discussion Questions 307
Where to Go From Here 308
Recommended Supplementary Readings 310
11 Choice Theory/Reality
Therapy 311
introduction 313
Key Concepts 314
The Therapeutic Process 318
Application: Therapeutic Techniques and
Procedures 320
Choice Theory/Reality Therapy From a Multicultural
Perspective 327
reality Therapy applied to the case of stan 329
reality Therapy applied to the case of gwen 331
Summary and Evaluation 332
Self-Reflection and Discussion Questions 334
Where to Go From Here 334
Recommended Supplementary Readings 336
12 Feminist Therapy 337
introduction 339
Key Concepts 341
The Therapeutic Process 345
Application: Therapeutic Techniques and
Procedures 348
Feminist Therapy From a Multicultural
and Social Justice Perspective 354
feminist Therapy applied to the case of stan 355
feminist Therapy applied to the case of gwen 357
Summary and Evaluation 360
Self-Reflection and Discussion Questions 364
Where to Go From Here 364
Recommended Supplementary Readings 366
13 Postmodern Approaches 367
Some Contemporary Founders of Postmodern
Therapies 368
Introduction to Social Constructionism 368
Solution-Focused Brief Therapy 371
Narrative Therapy 382
Postmodern Approaches From a Multicultural
Perspective 390
Postmodern approaches applied to the case
of stan 392
Postmodern approaches applied to the case of
gwen 394
Summary and Evaluation 396
Self-Reflection and Discussion Questions 398
Where to Go From Here 399
Recommended Supplementary Readings 400
14 Family Systems Therapy 403
introduction 404
Development of Family Systems Therapy 406
A Multilayered Process of Family Therapy 409
Family Systems Therapy From a Multicultural
Perspective 415
family Therapy applied to the case of stan 417
family Therapy applied to the case of gwen 420
Summary and Evaluation 422
Self-Reflection and Discussion Questions 424
Where to Go From Here 424
Recommended Supplementary Readings 425
P A R T 3
INTEGRATION AND APPLICATION
15 An Integrative Perspective 427
introduction 428
The Movement Toward Psychotherapy
Integration 428
Issues Related to the Therapeutic Process 437
The Place of Techniques and Evaluation in
Counseling 443
an integrative approach applied to the case
of stan 452
an integrative approach applied to the case
of gwen 455
Summary 456
Concluding Comments 457
Self-Reflection and Discussion Questions 458
Where to Go From Here 458
Recommended Supplementary Readings 459
references and suggested readings 461
name index 481
subject index 485
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Preface to Tenth Edition
T his book is intended for counseling courses for undergraduate and graduate students in psychology, counselor education, human services, and the mental
health professions. It surveys the major concepts and practices of the contemporary
therapeutic systems and addresses some ethical and professional issues in counsel-
ing practice. The book aims to teach students to select wisely from various theories
and techniques and to begin to develop a personal style of counseling.
I have found that students appreciate an overview of the divergent contempo-
rary approaches to counseling and psychotherapy. They also consistently say that
the first course in counseling means more to them when it deals with them person-
ally. Therefore, I stress the practical applications of the material and encourage per-
sonal reflection. Using this book can be both a personal and an academic learning
experience.
In this tenth edition, every effort has been made to retain the major qualities
that students and professors have found useful in the previous editions: the succinct
overview of the key concepts of each theory and their implications for practice, the
straightforward and personal style, and the book’s comprehensive scope. Care has
been taken to present the theories in an accurate and fair way. I have attempted to
be simple, clear, and concise. Because many students want suggestions for supple-
mentary reading as they study each therapy approach, I have included an updated
reading list at the end of each chapter and a list of references for each chapter at the
end of the book.
This tenth edition updates the material and refines existing discussions. Part 1
deals with issues that are basic to the practice of counseling and psychotherapy.
Chapter 1 puts the book into perspective, then students are introduced to the
counselor—as a person and a professional—in Chapter 2. This chapter addresses a
number of topics pertaining to the role of the counselor as a person and the ther-
apeutic relationship. Chapter 3 introduces students to some key ethical issues in
counseling practice, and several of the topics in this chapter have been updated and
expanded. Expanded coverage is given to the ACA’s 2014 Code of Ethics.
Part 2 is devoted to a consideration of 11 theories of counseling. Each of the
theory chapters follows a common organizational pattern, and students can easily
compare and contrast the various models. This pattern includes core topics such as
key concepts, the therapeutic process, therapeutic techniques and procedures, mul-
ticultural perspectives, the theory applied to the case of Stan and new to this edition
to the case of Gwen, and summary and evaluation. In this tenth edition, each of the
chapters in Part 2 has been revised, updated, and expanded to reflect recent trends,
and references have been updated as well. Revisions were based on the recommenda-
tions of experts in each theory, all of whom are listed in the Acknowledgments sec-
tion. Attention was given to current trends and recent developments in the practice
of each theoretical approach.
xi
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xii P r e f a C e t o t e n t h e d i t i o n
Each of the 11 theory chapters summarizes key points and evaluates the con-
tributions, strengths, limitations, and applications of these theories. Special atten-
tion is given to evaluating each theory from a multicultural perspective as well, with
a commentary on the strengths and shortcomings of the theory in working with
diverse client populations. The consistent organization of the summary and evalu-
ation sections makes comparing theories easier. Students are given recommenda-
tions regarding where to look for further training for all of the approaches in the
Where To Go From Here sections at the end of the chapter. Updated annotated lists of
reading suggestions along with DVD resources are offered to stimulate students to
expand on the material and broaden their learning.
In Part 3, Chapter 15 develops the notion that an integrative approach to coun-
seling practice is in keeping with meeting the needs of diverse client populations in
many different settings. Numerous tables and other integrating material help stu-
dents compare and contrast the 11 approaches.
What’s new in This Tenth edition
Features of the tenth edition include Learning Objectives for all the theory chapters;
Self-Reflection and Discussion Questions at the end of each theory chapter to facilitate
thinking and interaction in class; and a new Case of Gwen, who is a composite of
many clients, to complement the Case of Stan feature. Guest contributor Dr. Kel-
lie Kirksey describes her way of working with Gwen from each of the theoretical
perspectives.
Significant changes for the tenth edition for each of the theory chapters are out-
lined below:
chapter 4 Psychoanalytic Therapy
�� New material on countertransference, its role in psychoanalytic therapy,
and guidelines for effectively dealing with countertransference
�� Expanded discussion of brief psychodynamic therapy and its application
chapter 5 adlerian Therapy
�� Revised material on the life tasks
�� More emphasis on goals for the educational process of therapy
�� More on the role of assessment and diagnosis
�� New material on early recollections with concrete examples
�� Many new examples to bring Adlerian concepts to life
�� Revised discussion of reorientation and encouragement process
�� Expanded discussion of Adlerian techniques
chapter 6 existential Therapy
�� Revised material on existential anxiety and its implications for therapy
�� Revised section on the client–therapist relationship
�� Expanded discussion of tasks of the existential therapist
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P r e f a C e t o t e n t h e d i t i o n xiii
chapter 7 Person-centered Therapy
�� Expanded discussion of clients as active self-healers
�� Updated coverage of the core conditions of congruence, unconditional
positive regard, and empathy
�� More attention to the diversity of styles of therapists practicing person-
centered therapy
�� More emphasis on how the basic philosophy of the person-centered
approach is appropriate for working with diverse client populations
�� A new section on emotion-focused therapy, stressing the role of emotions
as a route to change
�� Revised section on motivational interviewing (person-centered approach
with a twist)
chapter 8 gestalt Therapy
�� Revised discussion of the role of experiments in Gestalt therapy and
how they differ from techniques and structured exercises
�� New emphasis on therapist presence, the role of dialogue in therapy,
and the therapeutic relationship
�� Expanded discussion of therapist authenticity and self-disclosure
�� More attention to the contemporary relational approach to Gestalt
practice
chapter 9 behavior Therapy
�� Increased attention to the “third-generation” or “new wave” behavior
therapies
�� Updating of section on EMDR
�� Expanded and updated discussion of the role of mindfulness and
acceptance strategies in contemporary behavior therapy
�� New and expanded material on mindfulness-based cognitive therapy
and stress reduction
�� Expanded and revised treatment of dialectical behavior therapy
chapter 10 cognitive behavior Therapy
�� Major reorganization and updating of the entire chapter
�� Streamlining and updating of Albert Ellis’s rational emotive behavior
therapy
�� Revised and expanded coverage of Aaron Beck’s cognitive therapy
�� Increased coverage of Judith Beck’s role in the development of cognitive
therapy
�� New section on Christine Padesky’s strength-based cognitive behavior
therapy
�� Increased attention on Donald Meichenbaum’s influence in the devel-
opment of CBT
�� More clinical examples to illustrate key CBT techniques and concepts
�� Expanded coverage of a comparison among the various CBT approaches
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xiv P r e f a C e t o t e n t h e d i t i o n
chapter 11 choice Theory/reality Therapy
�� Revision of the relationship of choice theory to reality therapy
�� More practical examples of reality therapy practice
chapter 12 feminist Therapy
�� Updated and expanded treatment of the principles of feminist therapy
�� Increased attention given to cultural and social justice perspectives
�� More emphasis on concepts of power, privilege, discrimination, and
empowerment
�� Expansion of relational-cultural theory and implications for practice
�� Revised and expanded discussion on therapeutic techniques and
strategies
�� Revised material on strengths from a diversity perspective
chapter 13 Postmodern approaches
�� Updated coverage on parallels between solution-focused brief therapy
(SFBT) and positive psychology
�� Broadened discussion of the key concepts of SFBT
�� More emphasis on the client-as-expert in the therapy relationship in
postmodern approaches
�� More clinical examples to illustrate the use of SFBT techniques
�� New material on the defining characteristics of brief therapy
�� Increased emphasis on the collaborative nature of narrative therapy and
SFBT
�� Revision of narrative therapy section
chapter 14 family systems Therapy
�� Streamlined to focus mainly on an integrative approach to family
therapy
�� More on recent developments in family systems therapy
�� More attention given to feminism, multiculturalism, and postmodern
constructionism as applied to family therapy
Chapter 15 (“An Integrative Perspective”) pulls together themes from all 11 theo-
retical orientations. This chapter represents a major revision of the discussion of the
psychotherapy integration movement; updates of the various integrative approaches;
revision of the section on integration of spirituality in counseling; added material on
research demonstrating the therapeutic alliance; expanded discussion on the central
role of the client in determining therapy outcomes; new section on feedback-informed
treatment; and updated coverage of the conclusions from the research literature on the
effectiveness of psychotherapy. New to this chapter are two cases (Stan and Gwen) that
illustrate integrative approaches. Chapter 15 develops the notion that an integrative
approach to counseling practice is in keeping with meeting the needs of diverse client
populations in many different settings. Numerous tables and other integrating mate-
rial help students compare and contrast the 11 approaches.
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P r e f a C e t o t e n t h e d i t i o n xv
This text can be used in a flexible way. Some instructors will follow the sequenc-
ing of chapters in the book. Others will prefer to begin with the theory chapters
(Part 2) and then deal later with the student’s personal characteristics and ethical
issues. The topics can be covered in whatever order makes the most sense. Readers
are offered some suggestions for using this book in Chapter 1.
In this edition I have made every effort to incorporate those aspects that have
worked best in the courses on counseling theory and practice that I teach. To help
readers apply theory to practice, I have also revised the Student Manual, which is
designed for experiential work. The Student Manual for Theory and Practice of Counseling
and Psychotherapy still contains open-ended questions, many new cases for explora-
tion and discussion, structured exercises, self-inventories, and a variety of activities
that can be done both in class and out of class. The tenth edition features a struc-
tured overview, as well as a glossary, for each of the theories, and chapter quizzes for
assessing the level of student mastery of basic concepts. New to this tenth edition of
the Student Manual are experiential exercises for the Case of Gwen and questions raised
by experts in each of the theory chapters. Each expert addresses the same six ques-
tions as applied to each of the given theories.
MindTap™ is a new online resource available to accompany this textbook. It
contains the video program for Theory and Practice of Counseling and Psychotherapy: The
Case of Stan and Lecturettes, a glossary of key terms, interviews with experts (questions
and answers by experts in the various theories), and case examples for each of the
theories illustrating ways of applying these concepts and techniques to a counseling
case. A concise version of working with Stan from an integrative perspective now
appears in Chapter 15. Chapter 16, “Case Illustration: An Integrative Approach in
Working With Stan,” has been deleted from this edition but is available on Mind-
Tap™. A chapter covering Transactional Analysis is also available on MindTap™.
Case Approach to Counseling and Psychotherapy (Eighth Edition) features experts
working with the case of Ruth from the various therapeutic approaches. The case-
book, which is now available online, can supplement this book or stand alone.
Accompanying this tenth edition of the text and Student Manual are lecturettes
on how I draw from key concepts and techniques from the various theories pre-
sented in the book. This DVD program has been developed for student purchase
and use as a self-study program, and it completes an ideal learning package. The Art
of Integrative Counseling (Third Edition), which expands on the material in Chapter 15
of the textbook, also complements this book.
Some professors have found the textbook and the Student Manual or MindTap™
to be ideal companions and realistic resources for a single course. Others like to use
the textbook and the casebook as companions. With this revision it is now possible
to have a unique learning package of several books, along with the DVD for Integra-
tive Counseling: The Case of Ruth and Lecturettes. The Case Approach to Counseling and Psy-
chotherapy and the Art of Integrative Counseling can also be used in a various classes, a
few of which include case-management practicum, fieldwork courses, or counseling
techniques courses.
Also available is a revised and updated Instructor’s Resource Manual, which includes
suggestions for teaching the course, class activities to stimulate interest, PowerPoint
presentations for all chapters, and a variety of test questions and a final examina-
tion. This instructor’s manual is now geared for the following learning package:
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xvi P r e f a C e t o t e n t h e d i t i o n
Theory and Practice of Counseling and Psychotherapy, Student Manual for Theory and Practice
of Counseling and Psychotherapy, Case Approach to Counseling and Psychotherapy, The Art of
Integrative Counseling, and two video programs: DVD for Integrative Counseling: The Case
of Ruth and Lecturettes, and DVD for Theory and Practice of Counseling and Psychotherapy:
The Case of Stan and Lecturettes.
Acknowledgments
The suggestions I received from the many readers of prior editions who took the
time to complete the surveys have been most helpful in the revision process. Many
other people have contributed ideas that have found their way into this tenth edi-
tion. I especially appreciate the time and efforts of those who participated in a pre-
revision review and offered constructive criticism and supportive commentaries, as
well as those professors who have used this book and provided me with feedback
that has been most useful in these revisions. Those who reviewed selected parts of
the manuscript of the tenth edition are:
Jude Austin, doctoral student, University of Wyoming
Julius Austin, doctoral student, University of Wyoming
Mark E. Young, University of Central Florida
Robert Haynes, Borderline Productions
Beverly Palmer, California State University at Dominguez Hills
James Robert Bitter, East Tennessee State University
Patricia Robertson, East Tennessee State University
Jamie Bludworth, Arizona State University
Michelle Muratori, Johns Hopkins University
Jake Morris, Lipscomb University
Special thanks are extended to the chapter reviewers, who provided consultation
and detailed critiques. Their insightful and valuable comments have generally been
incorporated into this edition:
�� Chapter 4 (Psychoanalytic Therapy): William Blau, Copper Mountain College,
Joshua Tree, California
�� Chapter 5 (Adlerian Therapy): Matt Englar-Carlson, California State University,
Fullerton; Jon Carlson, Governors State University; Jon Sperry, Lynn University,
Boca Raton. James Robert Bitter, East Tennessee State University, and I coau-
thored Chapter 5.
�� Chapter 6 (Existential Therapy): Emmy van Deurzen, New School of Psy-
chotherapy and Counselling, London, England, and University of Sheffield;
J. Michael Russell of California State University, Fullerton; David N. Elkins,
Graduate School of Education and Psychology, Pepperdine University; Bryan
Farha, Oklahoma City College
�� Chapter 7 (Person-Centered Therapy): Natalie Rogers, Person-Centered Expres-
sive Arts Associates, Cotati, California; David N. Elkins, Graduate School of
Education and Psychology, Pepperdine University; David Cain, California
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P r e f a C e t o t e n t h e d i t i o n xvii
School of Professional Psychology at Alliant International University,
San Diego
�� Chapter 8 (Gestalt Therapy): Jon Frew, Private Practice, Vancouver, Washing-
ton, and Pacific University, Oregon; Lynne Jacobs, Pacific Gestalt Institute in
Los Angeles; Gary Yontef, Pacific Gestalt Institute in Los Angeles; Jude Austin,
doctoral student, University of Wyoming; Julius Austin, doctoral student, Uni-
versity of Wyoming
�� Chapter 9 (Behavior Therapy): Sherry Cormier, West Virginia University; Frank
M. Dattilio, Harvard Medical School, and the University of Pennsylvania
School of Medicine; Ronald D. Siegel, Harvard Medical School
�� Chapter 10 (Cognitive Behavior Therapy): Sherry Cormier, West Virginia
University; Christine A. Padesky, Center for Cognitive Therapy at Huntington
Beach, California; Frank M. Dattilio, Harvard Medical School, and the University
of Pennsylvania School of Medicine; Beverly Palmer, California State University
at Dominguez Hills; Jamie Bludworth, Arizona State University; Jude Austin,
doctoral student, University of Wyoming; Julius Austin, doctoral student,
University of Wyoming; Jon Sperry, Lynn University, Boca Raton; Debbie
Joffe Ellis
�� Chapter 11 (Choice Theory/Reality Therapy): Robert Wubbolding, Center for
Reality Therapy, Cincinnati, Ohio
�� Chapter 12 (Feminist Therapy): Carolyn Zerbe Enns, Cornell College; James
Robert Bitter, East Tennessee State University; Patricia Robertson, East Ten-
nessee State University; Elizabeth Kincade, Indiana University of Pennsylvania;
Susan Rachael Seem, The College at Brockport, State University of New York;
Kellie Kirksey, Cleveland Institute of Wellness; Amanda La Guardia of Sam
Houston State University. Barbara Herlihy, University of New Orleans, and I
coauthored Chapter 12.
�� Chapter 13 (Postmodern Approaches): John Winslade, California State University,
San Bernardino; John Murphy, University of Central Arkansas
�� Chapter 14 (Family Systems Therapy): James Robert Bitter, East Tennessee
State University, and I co-authored Chapter 14.
�� Chapter 15 (An Integrative Perspective): Scott D. Miller, The International
Center for Clinical Excellence; Beverly Palmer, California State University at
Dominguez Hills; Jude Austin, doctoral student, University of Wyoming;
Julius Austin, doctoral student, University of Wyoming
�� The Case of Gwen (all theory chapters) was written by Kellie Kirksey, Cleveland
Clinic Center for Integrative Medicine
This book is the result of a team effort, which includes the combined efforts of
a number of people at Cengage Learning. These people include Jon-David Hague,
Product Director; Julie Martinez, Product Manager, Counseling, Human Services,
and Social Work; Vernon Boes, Art Director, for his work on the interior design and
cover of this book; Kyra Kane, Associate Content Developer, who coordinates the
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xviii P r e f a C e t o t e n t h e d i t i o n
MindTap™ program and other supplementary materials for the book; Michelle
Muratori, Johns Hopkins University, for her work on updating the Instructor’s
Resource Manual and assisting in developing other supplements; and Rita Jaramillo,
Content Project Manager. Thanks to Ben Kolstad of Cenveo® Publisher Services,
who coordinated the production of this book. Special recognition goes to Kay Mikel,
the manuscript editor of this edition, whose exceptional editorial talents continue
to keep this book reader friendly. I appreciate Susan Cunningham’s work in creat-
ing and revising test items to accompany this text and in preparing the index. The
efforts and dedication of all of these people certainly contribute to the high quality
of this edition.
Gerald Corey
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1
1Introduction and Overview
1. Understand the author’s
philosophical stance.
2. Identify suggested ways to use this
book.
3. Differentiate between each
contemporary counseling model
discussed in this book.
4. Identify key issues within the case
of Stan.
5. Identify key issues within the case
of Gwen.
L e a r n i n g O b j e c t i v e s
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2 C H A P T E R O N E
Introduction
Counseling students can begin to acquire a counseling style tailored to their own
personality by familiarizing themselves with the major approaches to therapeu-
tic practice. This book surveys 11 approaches to counseling and psychotherapy,
presenting the key concepts of each approach and discussing features such as the
therapeutic process (including goals), the client–therapist relationship, and spe-
cific procedures used in the practice of counseling. This information will help you
develop a balanced view of the major ideas of each of the theories and acquaint
you with the practical techniques commonly employed by counselors who adhere
to each approach. I encourage you to keep an open mind and to seriously consider
both the unique contributions and the particular limitations of each therapeutic
system presented in Part 2.
You cannot gain the knowledge and experience you need to synthesize various
approaches by merely completing an introductory course in counseling theory. This
process will take many years of study, training, and practical counseling experience.
Nevertheless, I recommend a personal integration as a framework for the profes-
sional education of counselors. When students are presented with a single model
and are expected to subscribe to it alone, their effectiveness will be limited when
working with a diverse range of future clients.
An undisciplined mixture of approaches, however, can be an excuse for failing
to develop a sound rationale for systematically adhering to certain concepts and to
the techniques that are extensions of them. It is easy to pick and choose fragments
from the various therapies because they support our biases and preconceptions. By
studying the models presented in this book, you will have a better sense of how to
integrate concepts and techniques from different approaches when defining your
own personal synthesis and framework for counseling.
Each therapeutic approach has useful dimensions. It is not a matter of a theory
being “right” or “wrong,” as every theory offers a unique contribution to understand-
ing human behavior and has unique implications for counseling practice. Accepting
the validity of one model does not necessarily imply rejecting other models. There
is a clear place for theoretical pluralism, especially in a society that is becoming
increasingly diverse.
Although I suggest that you remain open to incorporating diverse approaches
into your own personal synthesis—or integrative approach to counseling—let me
caution that you can become overwhelmed and confused if you attempt to learn
everything at once, especially if this is your introductory course in counseling
theories. A case can be made for initially getting an overview of the major theoreti-
cal orientations, and then learning a particular approach by becoming steeped in
that approach for some time, rather than superficially grasping many theoretical
approaches. An integrative perspective is not developed in a random fashion; rather,
it is an ongoing process that is well thought out. Successfully integrating concepts
and techniques from diverse models requires years of reflective practice and a great
deal of reading about the various theories. In Chapter 15 I discuss in more depth
some ways to begin designing your integrative approach to counseling practice.
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I N T R O d u C T I O N A N d O v E R v I E w 3
visit CengageBrain.com or watch the dvd for the video program on Chapter 1, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecturette for each chapter in this book prior to reading the chapter.
Where I Stand
My philosophical orientation is strongly influenced by the existential
approach. Because this approach does not prescribe a set of techniques and pro-
cedures, I draw techniques from the other models of therapy that are presented in
this book. I particularly like to use role-playing techniques. When people reenact
scenes from their lives, they tend to become more psychologically engaged than
when they merely report anecdotes about themselves. I also incorporate many tech-
niques derived from cognitive behavior therapy.
The psychoanalytic emphasis on early psychosexual and psychosocial develop-
ment is useful. Our past plays a crucial role in shaping our current personality and
behavior. I challenge the deterministic notion that humans are the product of their
early conditioning and, thus, are victims of their past. But I believe that an explora-
tion of the past is often useful, particularly to the degree that the past continues to
influence present-day emotional or behavioral difficulties.
I value the cognitive behavioral focus on how our thinking affects the way we feel
and behave. These therapies also emphasize current behavior. Thinking and feeling
are important dimensions, but it can be a mistake to overemphasize them and not
explore how clients are behaving. What people are doing often provides a good clue
to what they really want. I also like the emphasis on specific goals and on encourag-
ing clients to formulate concrete aims for their own therapy sessions and in life.
More approaches have been developing methods that involve collaboration
between therapist and client, making the therapeutic venture a shared responsibil-
ity. This collaborative relationship, coupled with teaching clients ways to use what
they learn in therapy in their everyday lives, empowers clients to take an active stance
in their world. It is imperative that clients be active, not only in their counseling
sessions but in daily life as well. Homework, collaboratively designed by clients and
therapists, can be a vehicle for assisting clients in putting into action what they are
learning in therapy.
A related assumption of mine is that we can exercise increasing freedom to cre-
ate our own future. Accepting personal responsibility does not imply that we can
be anything we want to be. Social, environmental, cultural, and biological realities
oftentimes limit our freedom of choice. Being able to choose must be considered
in the sociopolitical contexts that exert pressure or create constraints; oppression
is a reality that can restrict our ability to choose our future. We are also influenced
by our social environment, and much of our behavior is a product of learning and
conditioning. That being said, I believe an increased awareness of these contextual
forces enables us to address these realities. It is crucial to learn how to cope with the
external and internal forces that influence our decisions and behavior.
Feminist therapy has contributed an awareness of how environmental and social
conditions contribute to the problems of women and men and how gender-role
LO1
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4 C H A P T E R O N E
socialization leads to a lack of gender equality. Family therapy teaches us that it is
not possible to understand the individual apart from the context of the system. Both
family therapy and feminist therapy are based on the premise that to understand the
individual it is essential to take into consideration the interpersonal dimensions and
the sociocultural context rather than focusing primarily on the intrapsychic domain.
This comprehensive approach to counseling goes beyond understanding our internal
dynamics and addresses the environmental and systemic realities that influence us.
My philosophy of counseling challenges the assumption that therapy is exclu-
sively aimed at “curing” psychological “ailments.” Such a focus on the medical
model restricts therapeutic practice because it stresses deficits rather than strengths.
Instead, I agree with the postmodern approaches (see Chapter 13), which are
grounded on the assumption that people have both internal and external resources
to draw upon when constructing solutions to their problems. Therapists will view
these individuals quite differently if they acknowledge that their clients possess
competencies rather than pathologies. I view each individual as having resources
and competencies that can be discovered and built upon in therapy.
Psychotherapy is a process of engagement between two people, both of whom
are bound to change through the therapeutic venture. At its best, this is a collabora-
tive process that involves both the therapist and the client in co-constructing solu-
tions regarding life’s tasks. Most of the theories described in this book emphasize
the collaborative nature of the practice of psychotherapy.
Therapists are not in business to change clients, to give them quick advice, or to
solve their problems for them. Instead, counselors facilitate healing through a pro-
cess of genuine dialogue with their clients. The kind of person a therapist is remains
the most critical factor affecting the client and promoting change. If practitioners
possess wide knowledge, both theoretical and practical, yet lack human qualities of
compassion, caring, good faith, honesty, presence, realness, and sensitivity, they are
more like technicians. I believe that those who function exclusively as technicians do
not make a significant difference in the lives of their clients. It is essential that coun-
selors explore their own values, attitudes, and beliefs in depth and work to increase
their own awareness. Throughout the book I encourage you to find ways to apply
what you are reading to your personal life. Doing so will take you beyond a mere
academic understanding of these theories.
With respect to mastering the techniques of counseling and applying them
appropriately and effectively, it is my belief that you are your own very best tech-
nique. Your engagement with your clients is useful in moving the therapeutic pro-
cess along. It is impossible to separate the techniques you use from your personality
and the relationship you have with your clients.
Administering techniques to clients without regard for the relationship vari-
ables is ineffective. Techniques cannot substitute for the hard work it takes to
develop a constructive client–therapist relationship. Although you can learn atti-
tudes and skills and acquire certain knowledge about personality dynamics and the
therapeutic process, much of effective therapy is the product of artistry. Counseling
entails far more than becoming a skilled technician. It implies that you are able to
establish and maintain a good working relationship with your clients, that you can
draw on your own experiences and reactions, and that you can identify techniques
suited to the needs of your clients.
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I N T R O d u C T I O N A N d O v E R v I E w 5
As a counselor, you need to remain open to your own personal development and
to address your personal problems. The most powerful ways for you to teach your
clients is by the behavior you model and by the ways you connect with them. I sug-
gest you experience a wide variety of techniques yourself as a client. Reading about a
technique in a book is one thing; actually experiencing it from the vantage point of a
client is quite another. If you have practiced mindfulness exercises, for example, you
will have a much better sense for guiding clients in the practice of becoming increas-
ingly mindful in daily life. If you have carried out real-life homework assignments
as part of your own self-change program, you can increase your empathy for clients
and their potential problems. Your own anxiety over self-disclosing and addressing
personal concerns can be a most useful anchoring point as you work with the anxiet-
ies of your clients. The courage you display in your own personal therapy will help
you appreciate how essential courage is for your clients.
Your personal characteristics are of primary importance in becoming a counselor,
but it is not sufficient to be merely a good person with good intentions. To be effective,
you also must have supervised experiences in counseling and sound knowledge of
counseling theory and techniques. Further, it is essential to be well grounded in the
various theories of personality and to learn how they are related to theories of counseling.
Your conception of the person and the individual characteristics of your client affect
the interventions you will make. Differences between you and your client may require
modification of certain aspects of the theories. Some practitioners make the mistake
of relying on one type of intervention (supportive, confrontational, information giv-
ing) for most clients with whom they work. In reality, different clients may respond
better to one type of intervention than to another. Even during the course of an
individual’s therapy, different interventions may be needed at different times. Prac-
titioners should acquire a broad base of counseling techniques that are suitable for
individual clients rather than forcing clients to fit one approach to counseling.
Suggestions for Using the Book
Here are some specific recommendations on how to get the fullest value from
this book. The personal tone of the book invites you to relate what you are reading
to your own experiences. As you read Chapter 2, “The Counselor: Person and Profes-
sional,” begin the process of reflecting on your needs, motivations, values, and life
experiences. Consider how you are likely to bring the person you are becoming into
your professional work. You will assimilate much more knowledge about the vari-
ous therapies if you make a conscious attempt to apply the key concepts and tech-
niques of these theories to your own personal life. Chapter 2 helps you think about
how to use yourself as your single most important therapeutic instrument, and it
addresses a number of significant ethical issues in counseling practice.
Before you study each of the theories chapters, I suggest that you at least briefly
read Chapter 15, which provides a comprehensive review of the key concepts from
all 11 theories presented in this textbook. I try to show how an integration of these
perspectives can form the basis for creating your own personal synthesis to coun-
seling. In developing an integrative perspective, it is essential to think holistically.
To understand human functioning, it is imperative to account for the physical,
LO2
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6 C H A P T E R O N E
emotional, mental, social, cultural, political, and spiritual dimensions. If any one of
these facets of human experience is neglected, a theory is limited in explaining how
we think, feel, and act.
To provide you with a consistent framework for comparing and contrasting
the various therapies, the 11 theory chapters share a common format. This format
includes a few notes on the personal history of the founder or another key figure;
a brief historical sketch showing how and why each theory developed at the time
it did; a discussion of the approach’s key concepts; an overview of the therapeutic
process, including the therapist’s role and client’s work; therapeutic techniques and
procedures; applications of the theory from a multicultural perspective; application
of the theory to the cases of Stan and Gwen; a summary; a critique of the theory with
emphasis on contributions and limitations; suggestions of how to continue your
learning about each approach; and suggestions for further reading.
Refer to the Preface for a complete description of other resources that fit as a
package and complement this textbook, including Student Manual for Theory and
Practice of Counseling and Psychotherapy and DVD for Integrative Counseling: The Case of
Ruth and Lecturettes. In addition, in DVD for Theory and Practice of Counseling and Psycho-
therapy: The Case of Stan and Lecturettes I demonstrate my way of counseling Stan from
the various theoretical approaches in 13 sessions and present my perspective on the
key concepts of each theory in a brief lecture, with emphasis on the practical applica-
tion of the theory.
Overview of the Theory Chapters
I have selected 11 therapeutic approaches for this book. Table 1.1 presents
an overview of these approaches, which are explored in depth in Chapters 4 through
14. I have grouped these approaches into four general categories.
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TabLe 1.1 Overview of Contemporary Counseling Models
Psychodynamic Approaches
Psychoanalytic therapy Founder: Sigmund Freud. A theory of personality development, a philosophy of human
nature, and a method of psychotherapy that focuses on unconscious factors that motivate
behavior. Attention is given to the events of the first six years of life as determinants of the
later development of personality.
Adlerian therapy Founder: Alfred Adler. Key Figure: Following Adler, Rudolf Dreikurs is credited with
popularizing this approach in the United States. This is a growth model that stresses
assuming responsibility, creating one’s own destiny, and finding meaning and goals to create
a purposeful life. Key concepts are used in most other current therapies.
Experiential and Relationship-Oriented Therapies
Existential therapy Key figures: Viktor Frankl, Rollo May, and Irvin Yalom. Reacting against the tendency to
view therapy as a system of well-defined techniques, this model stresses building therapy
on the basic conditions of human existence, such as choice, the freedom and responsibility
to shape one’s life, and self-determination. It focuses on the quality of the person-to-person
therapeutic relationship.
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I N T R O d u C T I O N A N d O v E R v I E w 7
Person-centered therapy Founder: Carl Rogers; Key figure: Natalie Rogers. This approach was developed during the
1940s as a nondirective reaction against psychoanalysis. Based on a subjective view of
human experiencing, it places faith in and gives responsibility to the client in dealing with
problems and concerns.
Gestalt therapy Founders: Fritz and Laura Perls; Key figures: Miriam and Erving Polster. An experiential
therapy stressing awareness and integration; it grew as a reaction against analytic therapy.
It integrates the functioning of body and mind and places emphasis on the therapeutic
relationship.
Cognitive Behavioral Approaches
Behavior therapy Key figures: B. F. Skinner, and Albert Bandura. This approach applies the principles of
learning to the resolution of specific behavioral problems. Results are subject to continual
experimentation. The methods of this approach are always in the process of refinement. The
mindfulness and acceptance-based approaches are rapidly gaining popularity.
Cognitive behavior therapy Founders: Albert Ellis and A. T. Beck. Albert Ellis founded rational emotive behavior therapy,
a highly didactic, cognitive, action-oriented model of therapy, and A. T. Beck founded
cognitive therapy, which gives a primary role to thinking as it influences behavior. Judith
Beck continues to develop CBT; Christine Padesky has developed strengths-based CBT;
and Donald Meichenbaum, who helped develop cognitive behavior therapy, has made
significant contributions to resilience as a factor in coping with trauma.
Choice theory/Reality
therapy
Founder: William Glasser. Key figure: Robert Wubbolding. This short-term approach is based
on choice theory and focuses on the client assuming responsibility in the present. Through
the therapeutic process, the client is able to learn more effective ways of meeting her or his
needs.
Systems and Postmodern Approaches
Feminist therapy This approach grew out of the efforts of many women, a few of whom are Jean Baker
Miller, Carolyn Zerbe Enns, Oliva Espin, and Laura Brown. A central concept is the concern
for the psychological oppression of women. Focusing on the constraints imposed by the
sociopolitical status to which women have been relegated, this approach explores women’s
identity development, self-concept, goals and aspirations, and emotional well-being.
Postmodern approaches A number of key figures are associated with the development of these various approaches
to therapy. Steve de Shazer and Insoo Kim Berg are the cofounders of solution-focused brief
therapy. Michael White and David Epston are the major figures associated with narrative
therapy. Social constructionism, solution-focused brief therapy, and narrative therapy all
assume that there is no single truth; rather, it is believed that reality is socially constructed
through human interaction. These approaches maintain that the client is an expert in his or
her own life.
Family systems therapy A number of significant figures have been pioneers of the family systems approach, two
of whom include Murray Bowen and Virginia Satir. This systemic approach is based on the
assumption that the key to changing the individual is understanding and working with the
family.
First are the psychodynamic approaches. Psychoanalytic therapy is based largely on
insight, unconscious motivation, and reconstruction of the personality. The psy-
choanalytic model appears first because it has had a major influence on all of the
formal systems of psychotherapy. Some of the therapeutic models are extensions of
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8 C H A P T E R O N E
psychoanalysis, others are modifications of analytic concepts and procedures, and
still others emerged as a reaction against psychoanalysis. Many theories of psycho-
therapy have borrowed and integrated principles and techniques from psychoana-
lytic approaches.
Adlerian therapy differs from psychoanalytic theory in many respects, but it can
broadly be considered an analytic perspective. Adlerians focus on meaning, goals,
purposeful behavior, conscious action, belonging, and social interest. Although
Adlerian theory accounts for present behavior by studying childhood experiences, it
does not focus on unconscious dynamics.
The second category comprises the experiential and relationship-oriented therapies:
the existential approach, the person-centered approach, and Gestalt therapy. The
existential approach stresses a concern for what it means to be fully human. It suggests
certain themes that are part of the human condition, such as freedom and respon-
sibility, anxiety, guilt, awareness of being finite, creating meaning in the world, and
shaping one’s future by making active choices. This approach is not a unified school
of therapy with a clear theory and a systematic set of techniques. Rather, it is a philos-
ophy of counseling that stresses the divergent methods of understanding the subjec-
tive world of the person. The person-centered approach, which is rooted in a humanistic
philosophy, places emphasis on the basic attitudes of the therapist. It maintains
that the quality of the client–therapist relationship is the prime determinant of the
outcomes of the therapeutic process. Philosophically, this approach assumes that
clients have the capacity for self-direction without active intervention and direction
on the therapist’s part. Another experiential approach is Gestalt therapy, which offers
a range of experiments to help clients gain awareness of what they are experiencing
in the here and now—that is, the present. In contrast to person-centered therapists,
Gestalt therapists tend to take an active role, yet they follow the leads provided by
their clients. These approaches tend to emphasize emotion as a route to bringing
about change, and in a sense, they can be considered emotion-focused therapies.
Third are the cognitive behavioral approaches, sometimes known as the action-
oriented therapies because they all emphasize translating insights into behavioral
action. These approaches include choice theory/reality therapy, behavior therapy,
rational emotive behavior therapy, and cognitive therapy. Reality therapy focuses on
clients’ current behavior and stresses developing clear plans for new behaviors. Like
reality therapy, behavior therapy puts a premium on doing and on taking steps to make
concrete changes. A current trend in behavior therapy is toward paying increased
attention to cognitive factors as an important determinant of behavior. Rational emo-
tive behavior therapy and cognitive therapy highlight the necessity of learning how to
challenge inaccurate beliefs and automatic thoughts that lead to behavioral prob-
lems. These cognitive behavioral approaches are used to help people modify their
inaccurate and self-defeating assumptions and to develop new patterns of acting.
The fourth general approach encompasses the systems and postmodern perspectives.
Feminist therapy and family therapy are systems approaches, but they also share
postmodern notions. The systems orientation stresses the importance of under-
standing individuals in the context of the surroundings that influence their devel-
opment. To bring about individual change, it is essential to pay attention to how
the individual’s personality has been affected by his or her gender-role socialization,
culture, family, and other systems.
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I N T R O d u C T I O N A N d O v E R v I E w 9
The postmodern approaches include social constructionism, solution-focused brief
therapy, and narrative therapy. These newer approaches challenge the basic assump-
tions of most of the traditional approaches by assuming that there is no single truth
and that reality is socially constructed through human interaction. Both the post-
modern and the systemic theories focus on how people produce their own lives in
the context of systems, interactions, social conditioning, and discourse.
In my view, practitioners need to pay attention to what their clients are thinking,
feeling, and doing, and a complete therapy system must address all three of these fac-
ets. Some of the therapies included here highlight the role that cognitive factors play
in counseling. Others place emphasis on the experiential aspects of counseling and
the role of feelings. Still others emphasize putting plans into action and learning by
doing. Combining all of these dimensions provides the basis for a comprehensive
therapy.
Introduction to the Case of Stan
You will learn a great deal by seeing a theory in action, preferably in a live
demonstration or as part of experiential activities in which you function in the alter-
nating roles of client and counselor. An online program (available in DVD format as
well) demonstrates one or two techniques from each of the theories. As Stan’s coun-
selor, I show how I would apply some of the principles of each of the theories you are
studying to Stan. Many of my students find this case history of the hypothetical cli-
ent (Stan) helpful in understanding how various techniques are applied to the same
person. Stan’s case, which describes his life and struggles, is presented here to give
you significant background material to draw from as you study the applications of
the theories. Each of the 11 theory chapters in Part 2 includes a discussion of how
a therapist with the orientation under discussion is likely to proceed with Stan. We
examine the answers to questions such as these:
�� What themes in Stan’s life merit special attention in therapy?
�� What concepts would be useful to you in working with Stan on his
problems?
�� What are the general goals of Stan’s therapy?
�� What possible techniques and methods would best meet these goals?
�� What are some characteristics of the relationship between Stan and his
therapist?
�� How might the therapist proceed?
�� How might the therapist evaluate the process and treatment outcomes
of therapy?
In Chapter 15 (which I recommend you read early) I explain how I would work with
Stan, suggesting concepts and techniques I would draw on from many of the mod-
els (forming an integrative approach).
A single case illustrates both contrasts and parallels among the approaches.
It also will help you understand the practical applications of the 11 models and
provide a basis for integrating them. A summary of the intake interview with Stan,
his autobiography, and some key themes in his life are presented next to provide a
context for making sense of the way therapists with various theoretical orientations
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10 C H A P T E R O N E
might work with Stan. Try to find attributes of each approach that you can incorpo-
rate into a personalized style of counseling.
Intake Interview and Stan’s Autobiography
The setting is a community mental health agency where both individual and group
counseling are available. Stan comes to counseling because of his drinking. He was
convicted of driving under the influence, and the judge determined that he needed
professional help. Stan recognizes that he does have problems, but he is not con-
vinced that he is addicted to alcohol. Stan arrives for an intake interview and pro-
vides the counselor with this information:
At the present time I work in construction. I like building houses, but probably
won’t stay in construction for the rest of my life. When it comes to my personal
life, I’ve always had difficulty in getting along with people. I could be called a
“loner.” I like people in my life, but I don’t seem to know how to stay close to
people. It probably has a lot to do with why I drink. I’m not very good at making
friends or getting close to people. Probably the reason I sometimes drink a bit too
much is because I’m so scared when it comes to socializing. Even though I hate
to admit it, when I drink, things are not quite so overwhelming. When I look at
others, they seem to know the right things to say. Next to them I feel dumb. I’m
afraid that people don’t find me very interesting. I’d like to turn my life around,
but I just don’t know where to begin. That’s why I went back to school. I’m a part-
time college student majoring in psychology. I want to better myself. In one of my
classes, Psychology of Personal Adjustment, we talked about ourselves and how
people change. We also had to write an autobiographical paper.
That is the essence of Stan’s introduction. The counselor says that she would
like to read his autobiography. Stan hopes it will give her a better understanding of
where he has been and where he would like to go. He brings her the autobiography,
which reads as follows:
Where am I currently in my life? At 35 I feel that I’ve wasted most of my life. I
should be finished with college and into a career by now, but instead I’m only a
junior. I can’t afford to really commit myself to pursuing college full time because
I need to work to support myself. Even though construction work is hard, I like
the satisfaction I get when I look at what I have done.
I want to get into a profession where I could work with people. Someday, I’m
hoping to get a master’s degree in counseling or in social work and eventually
work as a counselor with kids who are in trouble. I know I was helped by someone
who cared about me, and I would like to do the same for someone else.
I have few friends and feel scared around most people. I feel good with
kids. But I wonder if I’m smart enough to get through all the classes I’ll need
to become a counselor. One of my problems is that I frequently get drunk. This
happens when I feel alone and when I’m scared of the intensity of my feelings. At
first drinking seemed to help, but later on I felt awful. I have abused drugs in the
past also.
I feel overwhelmed and intimidated when I’m around attractive women. I feel
cold, sweaty, and terribly nervous. I think they may be judging me and see me as not
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I N T R O d u C T I O N A N d O v E R v I E w 11
much of a man. I’m afraid I just don’t measure up to being a real man. When I am
sexually intimate with a woman, I am anxious and preoccupied with what she is
thinking about me.
I feel anxiety much of the time. I often feel as if I’m dying inside. I think about
committing suicide, and I wonder who would care. I can see my family coming to
my funeral feeling sorry for me. I feel guilty that I haven’t worked up to my poten-
tial, that I’ve been a failure, that I’ve wasted much of my time, and that I let people
down a lot. I get down on myself and wallow in guilt and feel very depressed. At
times like this I feel hopeless and that I’d be better off dead. For all these reasons,
I find it difficult to get close to anyone.
There are a few bright spots. I did put a lot of my shady past behind me, and
did get into college. I like this determination in me—I want to change. I’m tired of
feeling the way I do. I know that nobody is going to change my life for me. It’s up
to me to get what I want. Even though I feel scared at times, I like that I’m willing
to take risks.
What was my past like? A major turning point for me was the confidence my
supervisor had in me at the youth camp where I worked the past few summers.
He helped me get my job, and he also encouraged me to go to college. He said he
saw a lot of potential in me for being able to work well with young people. That
was hard for me to believe, but his faith inspired me to begin to believe in myself.
Another turning point was my marriage and divorce. This marriage didn’t last
long. It made me wonder about what kind of man I was! Joyce was a strong and
dominant woman who kept repeating how worthless I was and how she did not
want to be around me. We had sex only a few times, and most of the time I was not
very good at it. That was hard to take. It made me afraid to get close to a woman.
My parents should have divorced. They fought most of the time. My mother
(Angie) constantly criticized my father (Frank Sr.). I saw him as weak and passive.
He would never stand up to her. There were four of us kids. My parents compared
me unfavorably with my older sister (Judy) and older brother (Frank Jr.). They
were “perfect” children, successful honors’ students. My younger brother (Karl)
and I fought a lot. They spoiled him. It was all very hard for me.
In high school I started using drugs. I was thrown into a youth rehabilita-
tion facility for stealing. Later I was expelled from regular school for fighting,
and I landed in a continuation high school, where I went to school in the morn-
ings and had afternoons for on-the-job training. I got into auto mechanics, was
fairly successful, and even managed to keep myself employed for three years as a
mechanic.
I can still remember my father asking me: “Why can’t you be like your sister
and brother? Why can’t you do anything right?” And my mother treated me much
the way she treated my father. She would say: “Why do you do so many things to
hurt me? Why can’t you grow up and be a man? Things are so much better around
here when you’re gone.” I recall crying myself to sleep many nights, feeling terribly
alone. There was no talk of religion in my house, nor was there any talk of sex. In
fact, I find it hard to imagine my folks ever having sex.
Where would I like to be five years from now? What kind of person do I want
to become? Most of all, I would like to start feeling better about myself. I would
like to be able to stop drinking altogether and still feel good. I want to like myself
much more than I do now. I hope I can learn to love at least a few other people,
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12 C H A P T E R O N E
most of all, a woman. I want to lose my fear of women. I would like to feel equal
with others and not always have to feel apologetic for my existence. I want to let
go of my anxiety and guilt. I want to become a good counselor for kids. I’m not
certain how I’ll change or even what all the changes are I hope for. I do know that
I want to be free of my self-destructive tendencies and learn how to trust people
more. Perhaps when I begin to like myself more, I’ll be able to trust that others will
find something about me to like.
Effective therapists, regardless of their theoretical orientation, would pay
attention to suicidal thoughts. In his autobiography Stan says, “I think about
committing suicide.” At times he doubts that he will ever change and wonders if
he’d be “better off dead.” Before embarking on the therapeutic journey, the thera-
pist would need to make an assessment of Stan’s current ego strength (or his abil-
ity to manage life realistically), which would include a discussion of his suicidal
thoughts.
Overview of Some Key Themes in Stan’s Life
A number of themes appear to represent core struggles in Stan’s life. Here are some
of the statements we can assume that he may make at various points in his therapy
and themes that will be addressed from the theoretical perspectives in Chapters 4
through 15:
�� Although I’d like to have people in my life, I just don’t seem to know
how to go about making friends or getting close to people.
�� I’d like to turn my life around, but I have no sense of direction.
�� I want to make a difference.
�� I am afraid of failure.
�� I know when I feel alone, scared, and overwhelmed, I drink heavily to
feel better.
�� I am afraid of women.
�� Sometimes at night I feel a terrible anxiety and feel as if I’m dying.
�� I often feel guilty that I’ve wasted my life, that I’ve failed, and that I’ve
let people down. At times like this, I get depressed.
�� I like it that I have determination and that I really want to change.
�� I’ve never really felt loved or wanted by my parents.
�� I’d like to get rid of my self-destructive tendencies and learn to trust
people more.
�� I put myself down a lot, but I’d like to feel better about myself.
In the chapters in Part 2, I write about how I would apply selected concepts and
techniques of the particular theory in counseling Stan. In addition, in these chapters
you are asked to think about how you would continue counseling Stan from each
of these different perspectives. In doing so, refer to the introductory material given
here and to Stan’s autobiography as well. To make the case of Stan come alive for
each theory, I highly recommend that you view and study the video program, DVD
for Theory and Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes.
In this video program I counsel Stan from each of the various theories and provide
brief lectures that highlight each theory.
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I N T R O d u C T I O N A N d O v E R v I E w 13
Introduction to the Case of Gwen
Meet Dr. Kellie Kirksey
Background on the Case of Gwen
Gwen is a 56-year-old, married African American woman presenting with
fibromyalgia, difficulty sleeping, and a history of anxiety and depression. She
reports feeling stress and isolation on her job and is having a difficult time manag-
ing her multiple roles. Gwen is the oldest of five children, and after her parents’
divorce, she took on the responsibility of caring for her younger siblings. Gwen has
been married to Ron for 31 years and states they have ups and downs but basically
their relationship is supportive. Ron is employed as a high school teacher and has
always made the family a priority. They have three adult children, Brittany age 29,
Lisa age 26, and Kevin age 23. Gwen has a master’s degree in accounting and is
employed at a large firm as a CPA. She reports being the only woman of color at her
job. Because she is the only one speaking up for issues of diversity and racial equal-
ity at her workplace, she often feels isolated and tired. She does not have enough
time to spend with friends or to do the things she once enjoyed because of her long
work hours. Gwen also helps her adult children with their bills when needed and
LO5
I invited Dr. Kellie Kirksey to create a case (“Gwen”)
based on a composite of her clients over her many years
of practice. Gwen’s concerns are discussed as they relate
to the theory featured in each chapter, and Dr. Kirksey
demonstrates how she would work with Gwen using
techniques that illustrate key concepts from the theory.
Kellie n. Kirksey, PhD, received her doctorate in
Counselor Education and Psychology at The Ohio State
University. She is a licensed clinical counselor, a certified
rehabilitation counselor, and an approved clinical super-
visor. She has practiced and taught in the counseling field
for more than 25 years and has focused her work in the
area of multicultural counseling, social justice, integrative counseling, and well-
ness. She was previously Associate Professor of Counselor Education at Malone
University in Ohio where she taught practicum, internship, group counseling,
theories, and cultural diversity. She is currently a Holistic Psychotherapist at the
Cleveland Clinic Center for Integrative Medicine and focuses primarily on using
holistic integrative methods such as hypnotherapy and meditation for health
and wellness. She also has a part-time clinical practice in Ohio.
Dr. Kirksey is a contributor to Gerald Corey’s Case Approach to Counseling
and Psychotherapy text in which she works with Ruth from a spiritually focused
integrative perspective. She enjoys exploring how wellness is achieved in other
cultures and has given numerous workshops and presentations on wellness and
self-care in North America, South Africa, Botswana, Hawaii, and Italy.
Kellie N. Kirksey
Ke
lli
e
Ki
rk
se
y
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14 C H A P T E R O N E
is the primary caretaker of her mother, who resides with her and is in the advanced
stages of dementia.
This is Gwen’s first time in formal counseling. She reports having gone to her
pastor when she was feeling “down” in the past. Gwen also reports times of being
sexually molested by an older cousin. She seeks counseling because she is having dif-
ficulty staying focused at work and is generally feeling sad and overwhelmed. Gwen
also reports experiencing a great deal of anxiety. She states she is not suicidal but is
“sick and tired of feeling sick and tired.” Gwen summarizes her current situation
by saying, “I realized the other day that I am tired of just existing and surviving. So
here I am.” Gwen was referred to Dr. Kirksey by the pastor of her church. Despite the
many challenges in her life, Gwen says that her faith in God is strong and church has
always been her place of refuge.
Intake Session
Gwen begins by saying she is ready to unload the stressors she has been holding
inside. She states that she has held everything together for everyone far too long.
During this initial session, I also address the relevant aspects of informed consent
and begin an ongoing process of educating Gwen on how the therapeutic process
works.
Gwen says she feels a heaviness in her heart, which is associated with all that is
expected of her at work and with her family, what she has not accomplished, and
where she is heading. I acknowledge this heaviness and ask her to start wherever she
wants. Gwen states that she has not felt carefree since she was a young child before
her parents’ divorce. Her parents moved to the North from Georgia for work when
she was 8 years old. Both of her parents were teachers and valued education. Her
neighborhood and school were predominantly African American, and the commu-
nity was close. In high school she was bussed across town to a predominately white
school, and Gwen states she began to encounter what she felt were racist attitudes
at this school. She reports:
I felt different and excluded and this was reinforced by occasional name calling
and subtle slights. That was one of the first times I remember feeling like I had
to work twice as hard to get ahead and to be accepted in life. Throughout college
I worked hard to be successful by pushing myself to achieve what people said I
couldn’t, but it seems that all my hard work has just worn me down.
A number of life concerns bring Gwen into counseling. A few of her concerns
relate to her work. She experiences mounting tension on the job and, when she
asserts her opinions, she is labeled as emotional and angry. The more tension she
experiences at work, the less she engages at home. An additional concern is that
her mother is slowly fading into another world due to dementia. Gwen states she is
feeling terrible about herself and not even wanting to be around people anymore.
Everything irritates her and she prefers to spend time by herself.
Gwen reports the following:
I feel like a shell of a person. I am not depressed where I am wanting to kill
myself. I just feel numb. There is no real point to doing this daily routine of
waking, suffering through the day, and going to bed just to get up and do it all
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I N T R O d u C T I O N A N d O v E R v I E w 15
over again. My life is like a flat note with little joy. I don’t go out; I don’t have sex;
and I am too tired to do anything. Nothing I do is good enough. I start projects,
and then it’s like they disappear. Nothing ever gets finished, and then I feel worse
about myself. Sometimes I feel like I want to go into a cave and never come out. I
feel like I will lose everything if I don’t make some changes in my life. Everything
looks good on the outside, but inside of me, I am on edge and need to do some-
thing different. My pastor and mentor tell me I am sabotaging myself. Usually, I
get defensive and withdrawn, but this time, I want to get better and I am ready to
do what it takes. I am done with feeling tired all the time and hiding from people.
My goal is to live a more balanced life and to learn how to reduce my stress level.
The first step of our journey is to build a working alliance based on mutual
respect. I let Gwen know that this is her time to use as she pleases, and that it is a
safe and confidential space.
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17
2The Counselor: Person and Professional
1. Identify the characteristics of the
counselor as a therapeutic person.
2. Understand the benefits of
seeking personal counseling as a
counselor.
3. Explain the concept of bracketing
and what is involved in managing
a counselor’s personal values.
4. Explain how values relate to
identifying goals in counseling.
5. Understand the role of diversity
issues in the therapeutic
relationship.
6. Describe what is involved in
acquiring competency as a
multicultural counselor.
7. Identify issues faced by beginning
therapists.
L e a r n i n g O b j e c t i v e s
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18 C H A P T E R T W O
Introduction
One of the most important instruments you have to work with as a counselor is
yourself as a person. In preparing for counseling, you will acquire knowledge about
the theories of personality and psychotherapy, learn assessment and intervention
techniques, and discover the dynamics of human behavior. Such knowledge and
skills are essential, but by themselves they are not sufficient for establishing and
maintaining effective therapeutic relationships. To every therapy session we bring
our human qualities and the experiences that have influenced us. In my judgment,
this human dimension is one of the most powerful influences on the therapeutic
process.
A good way to begin your study of contemporary counseling theories is by
reflecting on the personal issues raised in this chapter. By remaining open to self-
evaluation, you not only expand your awareness of self but also build the foundation
for developing your abilities and skills as a professional. The theme of this chapter is
that the person and the professional are intertwined facets that cannot be separated in
reality. We know, clinically and scientifically, that the person of the therapist and the
therapeutic relationship contribute to therapy outcome at least as much as the par-
ticular treatment method used (Duncan, Miller, Wampold, & Hubble, 2010; Elkins,
2016; Norcross, 2011).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 2, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
The Counselor as a Therapeutic Person
Counseling is an intimate form of learning, and it demands a practitio-
ner who is willing to be an authentic person in the therapeutic relationship. It is
within the context of such a person-to-person connection that the client experi-
ences growth. If we hide behind the safety of our professional role, our clients will
likely keep themselves hidden from us. If we strive for technical expertise alone, and
leave our own reactions and self out of our work, the result is likely to be ineffective
counseling. Our own genuineness can have a significant effect on our relationship
with our clients. If we are willing to look at our lives and make the changes we want,
we can model that process by the way we reveal ourselves and respond to our clients.
If we are inauthentic, we will have difficulty establishing a working alliance with
our clients. If we model authenticity by engaging in appropriate self-disclosure, our
clients will tend to be honest with us as well.
I believe that who the psychotherapist is directly relates to his or her ability to
establish and maintain effective therapy relationships with clients. But what does
the research reveal about the role of the counselor as a person and the therapeutic
relationship on psychotherapy outcome? Abundant research indicates the centrality
of the person of the therapist as a primary factor in successful therapy. The person of
the psychotherapist is inextricably intertwined with the outcome of psychotherapy
(see Elkins, 2016; Lambert, 2011; Norcross & Lambert, 2011; Norcross & Wampold,
2011). Clients place more value on the personality of the therapist than on the
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 19
specific techniques used. Indeed, evidence-based psychotherapy relationships are
critical to the psychotherapy endeavor.
Techniques themselves have limited importance in the therapeutic process.
Wampold (2001) conducted a meta-analysis of many research studies on therapeu-
tic effectiveness and found that the personal and interpersonal components are
essential to effective psychotherapy, whereas techniques have relatively little effect
on therapeutic outcome. The contextual factors—the alliance, the relationship, the per-
sonal and interpersonal skills of the therapist, client agency, and extra-therapeutic
factors—are the primary determinants of therapeutic outcome. This research sup-
ports what humanistic psychologists have maintained for years: “It is not theories
and techniques that heal the suffering client but the human dimension of therapy
and the ‘meetings’ that occur between therapist and client as they work together”
(Elkins, 2009, p. 82). In short, both the therapy relationship and the therapy methods
used influence the outcomes of treatment, but it essential that the methods used
support the therapeutic relationship being formed with the client.
Personal Characteristics of Effective Counselors
Particular personal qualities and characteristics of counselors are significant in
creating a therapeutic alliance with clients. My views regarding these personal
characteristics are supported by research on this topic (Norcross, 2011; Skovholt
& Jennings, 2004; Sperry & Carlson, 2011). I do not expect any therapist to fully
exemplify all the traits described in the list that follows. Rather, the willingness to
struggle to become a more therapeutic person is the crucial variable. This list is
intended to stimulate you to examine your own ideas about what kind of person
can make a significant difference in the lives of others.
�� Effective therapists have an identity. They know who they are, what they are
capable of becoming, what they want out of life, and what is essential.
�� Effective therapists respect and appreciate themselves. They can give and
receive help and love out of their own sense of self-worth and strength.
They feel adequate with others and allow others to feel powerful
with them.
�� Effective therapists are open to change. They exhibit a willingness and cour-
age to leave the security of the known if they are not satisfied with the
way they are. They make decisions about how they would like to change,
and they work toward becoming the person they want to become.
�� Effective therapists make choices that are life oriented. They are aware of early
decisions they made about themselves, others, and the world. They are
not the victims of these early decisions, and they are willing to revise
them if necessary. They are committed to living fully rather than set-
tling for mere existence.
�� Effective therapists are authentic, sincere, and honest. They do not hide behind
rigid roles or facades. Who they are in their personal life and in their
professional work is congruent.
�� Effective therapists have a sense of humor. They are able to put the events of
life in perspective. They have not forgotten how to laugh, especially at
their own foibles and contradictions.
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20 C H A P T E R T W O
�� Effective therapists make mistakes and are willing to admit them. They do not
dismiss their errors lightly, yet they do not choose to dwell on misery.
�� Effective therapists generally live in the present. They are not riveted to the
past, nor are they fixated on the future. They are able to experience and
be present with others in the “now.”
�� Effective therapists appreciate the influence of culture. They are aware of the
ways in which their own culture affects them, and they respect the diver-
sity of values espoused by other cultures. They are sensitive to the unique
differences arising out of social class, race, sexual orientation, and gender.
�� Effective therapists have a sincere interest in the welfare of others. This concern
is based on respect, care, trust, and a real valuing of others.
�� Effective therapists possess effective interpersonal skills. They are capable of
entering the world of others without getting lost in this world, and they
strive to create collaborative relationships with others. They readily
entertain another person’s perspective and can work together toward
consensual goals.
�� Effective therapists become deeply involved in their work and derive meaning
from it. They can accept the rewards flowing from their work, yet they
are not slaves to their work.
�� Effective therapists are passionate. They have the courage to pursue their
dreams and passions, and they radiate a sense of energy.
�� Effective therapists are able to maintain healthy boundaries. Although they
strive to be fully present for their clients, they don’t carry the problems
of their clients around with them during leisure hours. They know how
to say no, which enables them to maintain balance in their lives.
This picture of the characteristics of effective therapists might appear unrealistic.
Who could be all those things? Certainly I do not fit this bill! Do not think of these
personal characteristics from an all-or-nothing perspective; rather, consider them on
a continuum. A given trait may be highly characteristic of you, at one extreme, or it
may be very uncharacteristic of you, at the other extreme. I have presented this pic-
ture of the therapeutic person with the hope that you will examine it and develop
your own concept of what personality traits you think are essential to strive for to
promote your own personal growth. For a more detailed discussion of the person of
the counselor and the role of the therapeutic relationship in outcomes of treatments,
see Psychotherapy Relationships That Work (Norcross, 2011), How Master Therapists Work:
Exploring Change From the First Through the Last Session and Beyond (Sperry & Carlson,
2011), and Master Therapists: Exploring Expertise in Therapy and Counseling (Skovholt &
Jennings, 2004).
Personal Therapy for the Counselor
Discussion of the counselor as a therapeutic person raises another issue
debated in counselor education: Should people be required to participate in coun-
seling or therapy before they become practitioners? My view is that counselors can
benefit greatly from the experience of being clients at some time, a view that is sup-
ported by research. This experience can be obtained before your training, during it,
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 21
or both, but I strongly support some form of self-exploration as vital preparation in
learning to counsel others.
The vast majority of mental health professionals have experienced personal
therapy, typically on several occasions (Geller, Norcross, & Orlinsky, 2005b). A
review of research studies on the outcomes and impacts of the psychotherapist’s
own psychotherapy revealed that more than 90% of mental health professionals
report satisfaction and positive outcomes from their own counseling experiences
(Orlinsky, Norcross, Ronnestad, & Wiseman, 2005). Orlinsky and colleagues sug-
gest that personal therapy contributes to the therapist’s professional work in the
following three ways: (1) as part of the therapist’s training, personal therapy offers
a model of therapeutic practice in which the trainee experiences the work of a more
experienced therapist and learns experientially what is helpful or not helpful; (2) a
beneficial experience in personal therapy can further enhance a therapist’s interper-
sonal skills that are essential to skillfully practicing therapy; and (3) successful per-
sonal therapy can contribute to a therapist’s ability to deal with the ongoing stresses
associated with clinical work.
In his research on personal therapy for mental health professionals, Norcross
(2005) states that lasting lessons practitioners learn from their personal therapy
experiences pertain to interpersonal relationships and the dynamics of psychother-
apy. Some of these lessons learned are the centrality of warmth, empathy, and the
personal relationship; having a sense of what it is like to be a therapy client; valuing
patience and tolerance; and appreciating the importance of learning how to deal
with transference and countertransference. By participating in personal therapy,
counselors can prevent their potential future countertransference from harming
clients.
Through our work as therapists, we can expect to confront our own unexplored
personal blocks such as loneliness, power, death, and intimate relationships. This
does not mean that we need to be free of conflicts before we can counsel others, but
we should be aware of what these conflicts are and how they are likely to affect us
as persons and as counselors. For example, if we have great difficulty dealing with
anger or conflict, we may not be able to assist clients who are dealing with anger or
with relationships in conflict.
When I began counseling others, old wounds were opened and feelings I had
not explored in depth came to the surface. It was difficult for me to encounter a cli-
ent’s depression because I had failed to come to terms with the way I had escaped
from my own depression. I did my best to cheer up depressed clients by talking them
out of what they were feeling, mainly because of my own inability to deal with such
feelings. In the years I worked as a counselor in a university counseling center, I
frequently wondered what I could do for my clients. I often had no idea what, if
anything, my clients were getting from our sessions. I couldn’t tell if they were get-
ting better, staying the same, or getting worse. It was very important to me to note
progress and see change in my clients. Because I did not see immediate results, I
had many doubts about whether I could become an effective counselor. What I did
not understand at the time was that my clients needed to struggle to find their own
answers. To see my clients feel better quickly was my need, not theirs, for then I would
know that I was helping them. It never occurred to me that clients often feel worse
for a time as they give up their defenses and open themselves to their pain. My early
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22 C H A P T E R T W O
experiences as a counselor showed me that I could benefit by participating in further
personal therapy to better understand how my personal issues were affecting my
professional work. I realized that periodic therapy, especially early in one’s career,
can be most useful.
Personal therapy can be instrumental in healing the healer. If student counsel-
ors are not actively involved in the pursuit of their own healing and growth, they will
probably have considerable difficulty entering the world of a client. As counselors,
can we take our clients any further than we have gone ourselves? If we are not com-
mitted personally to the value of examining our own life, how can we inspire clients
to examine their lives? By becoming clients ourselves, we gain an experiential frame
of reference with which to view ourselves. This provides a basis for understanding
and compassion for our clients, for we can draw on our own memories of reaching
impasses in our therapy, of both wanting to go farther and at the same time resisting
change. Our own therapy can help us develop patience with our patients! We learn
what it feels like to deal with anxieties that are aroused by self-disclosure and self-
exploration and how to creatively facilitate deeper levels of self-exploration in cli-
ents. As we increase our self-awareness through our own therapy, we gain increased
appreciation for the courage our clients display in their therapeutic journey. Gold
and Hilsenroth (2009) studied graduate clinicians and found that those who had
personal therapy felt more confident and were more in agreement with their clients
on the goals and tasks of treatment than were those who did not experience per-
sonal therapy. They further found that graduate clinicians who had experienced per-
sonal therapy were able to develop strong agreement with their clients on the goals
and tasks of treatment. Participating in a process of self-exploration can reduce
the chances of assuming an attitude of arrogance or of being convinced that we
are totally healed. Our own therapy helps us avoid assuming a stance of superiority
over others and makes it less likely that we would treat people as objects to be pitied
or disrespected. Indeed, experiencing counseling as a client is very different from
merely reading about the counseling process.
For a comprehensive discussion of personal therapy for counselors, see The Psy-
chotherapist’s Own Psychotherapy: Patient and Clinician Perspectives (Geller, Norcross, &
Orlinsky, 2005a).
The Counselor’s Values and the Therapeutic Process
As alluded to in the previous section, the importance of self-exploration for coun-
selors carries over to the values and beliefs we hold. My experience in teaching and
supervising students of counseling shows me how crucial it is that students be
aware of their values, of where and how they acquired them, and of how their values
can influence their interventions with clients.
The Role of Values in Counseling
Our values are core beliefs that influence how we act, both in our personal
and our professional lives. Personal values influence how we view counseling and
the manner in which we interact with clients, including the way we conduct client
assessments, our views of the goals of counseling, the interventions we choose, the
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 23
topics we select for discussion in a counseling session, how we evaluate progress,
and how we interpret clients’ life situations.
Although total objectivity cannot be achieved, we can strive to avoid being
encapsulated by our own worldview. We need to guard against the tendency to use
our power to influence clients to accept our values; persuading clients to accept or
adopt our value system is not a legitimate outcome of counseling. From my perspec-
tive, the counselor’s role is to create a climate in which clients can examine their
thoughts, feelings, and actions and to empower them to arrive at their own solu-
tions to problems they face. The counseling task is to assist individuals in finding
answers that are most congruent with their own values. It is not beneficial to provide
advice or to give clients your answers to their questions about life.
You may not agree with certain of your clients’ values, but you need to respect
their right to hold divergent values from yours. This is especially true when coun-
seling clients who have a different cultural background and perhaps do not share
your own core cultural values. Your role is to provide a safe and inviting environ-
ment in which clients can explore the congruence between their values and their
behavior. If clients acknowledge that what they are doing is not getting them what
they want, it is appropriate to assist them in developing new ways of thinking and
behaving to help them move closer to their goals. This is done with full respect for
their right to decide which values they will use as a framework for living. Individuals
seeking counseling need to clarify their own values and goals, make informed deci-
sions, choose a course of action, and assume responsibility and accountability for
the decisions they make.
Managing your personal values so that they do not contaminate the counseling
process is referred to as “bracketing.” Counselors are expected to set aside their per-
sonal beliefs and values when working with a wide range of clients (Kocet & Herlihy,
2014). Your core values may differ in many ways from the core values of your clients,
and they will bring you a host of problems framed by their own worldview. Some
clients may have felt rejected by others or suffered from discrimination, and they
should not be exposed to further discrimination by counselors who refuse to render
services to them because of differing values (Herlihy, Hermann, & Greden, 2014).
Counselors must have the ability to work with a range of clients with diverse
worldviews and values. Counselors may impose their values either directly or indi-
rectly. value imposition refers to counselors directly attempting to define a client’s
values, attitudes, beliefs, and behaviors. It is unethical for counselors to impose
their values in the therapeutic relationship. The American Counseling Association’s
(ACA, 2014) Code of Ethics is explicit regarding this matter:
Personal Values. Counselors are aware of—and avoid imposing—their own values, atti-
tudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees,
and research participants and seek training in areas in which they are at risk of
imposing their values onto clients, especially when the counselor’s values are incon-
sistent with the client’s goals or are discriminatory in nature. (Standard A.4.b.)
Value exploration is at the heart of why many counselor education programs
encourage or require personal therapy for counselors in training. Your personal
therapy sessions provide an opportunity for you to examine your beliefs and values
and to explore your motivations for wanting to share your belief system.
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24 C H A P T E R T W O
Clients are in a vulnerable position and require understanding and support
from a counselor rather than judgment. It can be burdensome for clients to be
saddled with your disclosure of not being able to get beyond value differences. Cli-
ents may interpret this as a personal rejection and suffer harm as a result. Coun-
seling is about working with clients within the framework of their value system. If
you experience difficulties over conflicting personal values with clients, the ethical
course of action is to seek supervision and learn ways to effectively manage these
differences. The counseling process is not about your personal values; it is about
the values and needs of your clients. Your task is to help clients explore and clarify
their beliefs and apply their values to solving their problems (Herlihy & Corey,
2015d).
The Role of Values in Developing Therapeutic Goals
Who should establish the goals of counseling? Almost all theories are in
agreement that it is largely the client’s responsibility to decide upon goals, collabo-
rating with the therapist as therapy proceeds. Counselors have general goals, which
are reflected in their behavior during the therapy session, in their observations of
the client’s behavior, and in the interventions they make. The general goals of coun-
selors must be congruent with the personal goals of the client.
Setting goals is inextricably related to values. The client and the counselor need
to explore what they hope to obtain from the counseling relationship, whether
they can work with each other, and whether their goals are compatible. Even more
important, it is essential that the counselor be able to understand, respect, and work
within the framework of the client’s world rather than forcing the client to fit into
the therapist’s scheme of values.
In my view, therapy ought to begin with an exploration of the client’s expec-
tations and goals. Clients initially tend to have vague ideas of what they expect
from therapy. They may be seeking solutions to problems, they may want to stop
hurting, they may want to change others so they can live with less anxiety, or they
may seek to be different so that some significant persons in their lives will be more
accepting of them. In some cases clients have no goals; they are in the therapist’s
office simply because they were sent for counseling by their parents, probation
officer, or teacher.
So where can a counselor begin? The initial interview can be used most pro-
ductively to focus on the client’s goals or lack of them. The therapist may begin by
asking any of these questions: “What do you expect from counseling? Why are you
here? What do you want? What do you hope to leave with? How is what you are cur-
rently doing working for you? What aspects of yourself or your life situation would
you most like to change?”
When a person seeks a counseling relationship with you, it is important to coop-
eratively discover what this person is expecting from the relationship. If you try to
figure out in advance how to proceed with a client, you may be depriving the client
of the opportunity to become an active partner in her or his own therapy. Why is
this person coming in for counseling? It is the client’s place to decide on the goals
of therapy. It is important to keep this focus in mind so that the client’s agenda is
addressed rather than an agenda of your own.
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Justin Wanke
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 25
Becoming an Effective Multicultural Counselor
Part of the process of becoming an effective counselor involves learning how
to recognize diversity issues and shaping one’s counseling practice to fit the client’s
worldview. It is an ethical obligation for counselors to develop sensitivity to cultural
differences if they hope to make interventions that are consistent with the values
of their clients. The therapist’s role is to assist clients in making decisions that are
congruent with their worldview, not to live by the therapist’s values.
Diversity in the therapeutic relationship is a two-way street. As a counselor, you
bring your own heritage with you to your work, so you need to recognize the ways in
which cultural conditioning has influenced the directions you take with your clients.
Unless the social and cultural context of clients and counselors are taken into consid-
eration, it is difficult to appreciate the nature of clients’ struggles. Counseling students
often hold values—such as making their own choices, expressing what they are feeling,
being open and self-revealing, and striving for independence—that differ from the val-
ues of clients from different cultural backgrounds. Some clients may be very slow to
disclose and have expectations about counseling that differ from those of therapist.
Counselors need to become aware of how clients from diverse cultures may perceive
them as therapists, as well as how clients may perceive the value of formal helping. It
is the task of counselors to determine whether the assumptions they have made about
the nature and functioning of therapy are appropriate for culturally diverse clients.
Clearly, effective counseling must take into account the impact of culture on the
client’s functioning, including the client’s degree of acculturation. culture is, quite
simply, the values and behaviors shared by a group of individuals. It is important to
realize that culture refers to more than ethnic or racial heritage; culture also includes
factors such as age, gender, religion, sexual orientation, physical and mental ability,
and socioeconomic status.
Acquiring Competencies in Multicultural Counseling
Effective counselors understand their own cultural conditioning, the cultural
values of their clients, and the sociopolitical system of which they are a part. Acquir-
ing this understanding begins with counselors’ awareness of the cultural origins
of any values, biases, and attitudes they may hold. Counselors from all cultural
groups must examine their expectations, attitudes, biases, and assumptions about
the counseling process and about persons from diverse groups. Recognizing our
biases and prejudices takes courage because most of us do not want to acknowledge
that we have cultural biases. Everyone has biases, but being unaware of the biased
attitudes we hold is an obstacle to client care. It takes a concerted effort and vigi-
lance to monitor our biases, attitudes, and values so that they do not interfere with
establishing and maintaining successful counseling relationships.
A major part of becoming a diversity-competent counselor involves challenging
the idea that the values we hold are automatically true for others. We also need to
understand how our values are likely to influence our practice with diverse clients
who embrace different values. Furthermore, becoming a diversity-competent practi-
tioner is not a destination that we arrive at once and for all; rather, it is an ongoing
process, a journey we take with our clients.
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26 C H A P T E R T W O
Sue, Arredondo, and McDavis (1992) and Arredondo and her colleagues (1996)
have developed a conceptual framework for competencies and standards in multi-
cultural counseling. Their dimensions of competency involve three areas: (1) beliefs
and attitudes, (2) knowledge, and (3) skills. For an in-depth treatment of multicul-
tural counseling and therapy competence, refer to Counseling the Culturally Diverse:
Theory and Practice (Sue & Sue, 2013).
Beliefs and Attitudes First, effective counselors have moved from being culturally
unaware to ensuring that their personal biases, values, or problems will not interfere
with their ability to work with clients who are culturally different from them. They
believe cultural self-awareness and sensitivity to one’s own cultural heritage are
essential for any form of helping. Counselors are aware of their positive and negative
emotional reactions toward people from other racial and ethnic groups that may
prove detrimental to establishing collaborative helping relationships. They seek to
examine and understand the world from the vantage point of their clients. They
respect clients’ religious and spiritual beliefs and values. They are comfortable with
differences between themselves and others in terms of race, ethnicity, culture, and
beliefs. Rather than maintaining that their cultural heritage is superior, they are
able to accept and value cultural diversity. They realize that traditional theories and
techniques may not be appropriate for all clients or for all problems. Culturally
skilled counselors monitor their functioning through consultation, supervision,
and further training or education.
Knowledge Second, culturally effective practitioners possess certain knowledge.
They know specifically about their own racial and cultural heritage and how it
affects them personally and professionally. Because they understand the dynamics of
oppression, racism, discrimination, and stereotyping, they are in a position to detect
their own racist attitudes, beliefs, and feelings. They understand the worldview
of their clients, and they learn about their clients’ cultural background. They do
not impose their values and expectations on their clients from differing cultural
backgrounds and avoid stereotyping clients. Culturally skilled counselors understand
that external sociopolitical forces influence all groups, and they know how these
forces operate with respect to the treatment of minorities. These practitioners are
aware of the institutional barriers that prevent minorities from utilizing the mental
health services available in their communities. They possess knowledge about the
historical background, traditions, and values of the client populations with whom
they work. They know about minority family structures, hierarchies, values, and
beliefs. Furthermore, they are knowledgeable about community characteristics and
resources. Those who are culturally skilled know how to help clients make use of
indigenous support systems. In areas where they are lacking in knowledge, they
seek resources to assist them. The greater their depth and breadth of knowledge of
culturally diverse groups, the more likely they are to be effective practitioners.
Skills and Intervention Strategies Third, effective counselors have acquired certain
skills in working with culturally diverse populations. Counselors take responsibility
for educating their clients about the therapeutic process, including matters such as
setting goals, appropriate expectations, legal rights, and the counselor’s orientation.
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 27
Multicultural counseling is enhanced when practitioners use methods and strategies
and define goals consistent with the life experiences and cultural values of their
clients. Such practitioners modify and adapt their interventions to accommodate
cultural differences. They do not force their clients to fit within one counseling
approach, and they recognize that counseling techniques may be culture-bound.
They are able to send and receive both verbal and nonverbal messages accurately and
appropriately. They become actively involved with minority individuals outside the
office (community events, celebrations, and neighborhood groups). They are willing
to seek out educational, consultative, and training experiences to enhance their
ability to work with culturally diverse client populations. They consult regularly with
other multiculturally sensitive professionals regarding issues of culture to determine
whether referral may be necessary.
Incorporating Culture in Counseling Practice
It is unrealistic to expect a counselor to know everything about the cultural back-
ground of a client, but some understanding of the client’s cultural and ethnic back-
ground is essential. There is much to be said for letting clients teach counselors
about relevant aspects of their culture. It is a good idea for counselors to ask clients
to provide them with the information they will need to work effectively. Incorporat-
ing culture into the therapeutic process is not limited to working with clients from a
certain ethnic or cultural background. It is critical that therapists take into account
the worldview and background of every client. Failing to do this seriously restricts
the potential impact of the therapeutic endeavor.
Counseling is by its very nature diverse in a multicultural society, so it is easy to
see that there are no ideal therapeutic approaches. Instead, different theories have
distinct features that have appeal for different cultural groups. Some theoretical
approaches have limitations when applied to certain populations. Effective multi-
cultural practice demands an open stance on the part of the practitioner, flexibility,
and a willingness to modify strategies to fit the needs and the situation of the indi-
vidual client. Practitioners who truly respect their clients will be aware of clients’
hesitations and will not be too quick to misinterpret this behavior. Instead, they will
patiently attempt to enter the world of their clients as much as they can. Although
practitioners may not have had the same experiences as their clients, the empathy
shown by counselors for the feelings and struggles of their clients is essential to
good therapeutic outcomes. We are more often challenged by our differences than
by our similarities to look at what we are doing.
Practical Guidelines in Addressing Culture If the counseling process is to be
effective, it is essential that cultural concerns be addressed with all clients. Here
are some guidelines that may increase your effectiveness when working with clients
from diverse backgrounds:
�� Learn more about how your own cultural background has influenced
your thinking and behaving. Take steps to increase your understanding
of other cultures.
�� Identify your basic assumptions, especially as they apply to diversity
in culture, ethnicity, race, gender, class, spirituality, religion, and
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28 C H A P T E R T W O
sexual orientation. Think about how your assumptions are likely to
affect your professional practice.
�� Examine where you obtained your knowledge about culture.
�� Remain open to ongoing learning of how the various dimensions of
culture may affect therapeutic work. Realize that this skill does not
develop quickly or without effort.
�� Be willing to identify and examine your own personal worldview and
any prejudices you may hold about other racial/ethnic groups.
�� Learn to pay attention to the common ground that exists among peo-
ple of diverse backgrounds.
�� Be flexible in applying the methods you use with clients. Don’t be wed-
ded to a specific technique if it is not appropriate for a given client.
�� Remember that practicing from a multicultural perspective can make
your job easier and can be rewarding for both you and your clients.
It takes time, study, and experience to become an effective multicultural coun-
selor. Multicultural competence cannot be reduced simply to cultural awareness and
sensitivity, to a body of knowledge, or to a specific set of skills. Instead, it requires a
combination of all of these factors.
Issues Faced by Beginning Therapists
When you complete formal course work and begin helping clients, you will
be challenged to integrate and to apply what you have learned. At that point, you are
likely to have some real concerns about your adequacy as a person and as a profes-
sional. Beginning therapists typically face a number of common issues as they learn
how to help others. Here are some useful guidelines to assist you in your reflection
on what it takes to become an effective counselor.
Dealing With Anxiety
Most beginning counselors have ambivalent feelings when meeting their first cli-
ents. A certain level of anxiety demonstrates that you are aware of the uncertainties
of the future with your clients and of your abilities to really be there for them. A
willingness to recognize and deal with these anxieties, as opposed to denying them,
is a positive sign. That we have self-doubts is normal; it is how we deal with them
that matters. One way is to openly discuss our self-doubts with a supervisor and
peers. The possibilities are rich for meaningful exchanges and for gaining support
from fellow interns who probably have many of the same concerns and anxieties.
Being Yourself and Self-Disclosure
If you feel self-conscious and anxious when you begin counseling, you may have a
tendency to be overly concerned with what the books say and with the mechanics
of how to proceed. Inexperienced therapists too often fail to appreciate the values
inherent in simply being themselves. If we are able to be ourselves in our thera-
peutic work, and appropriately disclose our reactions in counseling sessions, we
increase the chances of being authentic. It is this level of genuineness and presence
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 29
that enables us to connect with our clients and to establish an effective therapeutic
relationship with them.
It is possible to err by going to extremes in two different directions. At one end
are counselors who lose themselves in their fixed role and hide behind a professional
facade. These counselors are so caught up in maintaining stereotyped role expecta-
tions that little of their personal self shows through. Counselors who adopt this
behavior will likely remain anonymous to clients, and clients may perceive them as
hiding behind a professional role.
At the other end of the spectrum is engaging in too much self-disclosure. Some
counselors make the mistake of inappropriately burdening their clients with their
spontaneous impressions about their clients. Judging the appropriate amount of
self-disclosure can be a problem even for seasoned counselors, and it is often espe-
cially worrisome for new counselors. In determining the appropriateness of self-
disclosure, consider what to reveal, when to reveal, and how much to reveal. It may be
useful to mention something about ourselves from time to time, but we must be
aware of our motivations for making ourselves known in this way. Assess the readi-
ness of a client to hear these disclosures as well as the impact doing so might have
on the client. Remain observant during any self-disclosure to get a sense of how the
client is being affected by it.
The most productive form of self-disclosure is related to what is going on between
the counselor and the client within the counseling session. The skill of immediacy
involves revealing what we are thinking or feeling in the here and now with the cli-
ent, but be careful to avoid pronouncing judgments about the client. When done
in a timely way, sharing persistent reactions can facilitate therapeutic progress and
improve the quality of our relationship with the client. Even when we are talking
about reactions based on the therapeutic relationship, caution is necessary, and dis-
cretion and sensitivity are required in deciding what reactions we might share.
Avoiding Perfectionism
Perhaps one of the most common self-defeating beliefs with which we burden our-
selves is that we must never make a mistake. Although we may well know intellectu-
ally that humans are not perfect, emotionally we often feel that there is little room for
error. To be sure, you will make mistakes, whether you are a beginning or a seasoned
therapist. If our energies are tied up presenting an image of perfection, this will
affect our ability to be present for our clients. I tell students to question the notion
that they should know everything and be perfectly skilled. I encourage them to
share their mistakes or what they perceive as errors during their supervision meet-
ings. Students willing to risk making mistakes in supervised learning situations and
willing to reveal their self-doubts will find a direction that leads to growth.
Being Honest About Your Limitations
You cannot realistically expect to succeed with every client. It takes honesty to admit
that you cannot work successfully with every client. It is important to learn when and
how to make a referral for clients when your limitations prevent you from helping
them. However, there is a delicate balance between learning your realistic limits and
challenging what you sometimes think of as being “limits.” Before deciding that you
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Justin Wanke
Highlight
30 C H A P T E R T W O
do not have the life experiences or the personal qualities to work with a given popu-
lation, try working in a setting with a population you do not intend to specialize in.
This can be done through diversified field placements or visits to agencies.
Understanding Silence
Silent moments during a therapeutic session may seem like silent hours to a begin-
ning therapist, yet this silence can have many meanings. The client may be quietly
thinking about some things that were discussed earlier or evaluating some insight
just acquired. The client may be waiting for the therapist to take the lead and decide
what to say next, or the therapist may be waiting for the client to do this. Either the
client or the therapist may be distracted or preoccupied, or neither may have any-
thing to say for the moment. The client and the therapist may be communicating
without words. The silence may be refreshing, or the silence may be overwhelming.
Perhaps the interaction has been on a surface level, and both persons have some fear
or hesitancy about getting to a deeper level. When silence occurs, acknowledge and
explore with your client the meaning of the silence.
Dealing With Demands From Clients
A major issue that puzzles many beginning counselors is how to deal with clients
who seem to make constant demands. Because therapists feel they should extend
themselves in being helpful, they often burden themselves with the unrealistic idea
that they should give unselfishly, regardless of how great clients’ demands may be.
These demands may manifest themselves in a variety of ways. Clients may want to
see you more often or for a longer period than you can provide. They may want to
see you socially. Some clients may expect you to continually demonstrate how much
you care or demand that you tell them what to do and how to solve a problem. One
way of heading off these demands is to make your expectations and boundaries
clear during the initial counseling sessions or in the disclosure statement.
Dealing With Clients Who Lack Commitment
Involuntary clients may be required by a court order to obtain therapy, and you
may be challenged in your attempt to establish a working relationship with them.
It is possible to do effective work with mandated clients, but practitioners must
begin by openly discussing the nature of the relationship. Counselors who omit
preparation and do not address clients’ thoughts and feelings about coming to
counseling are likely to encounter resistance. It is critical that therapists not prom-
ise what they cannot or will not deliver. It is good practice to make clear the limits
of confidentiality as well as any other factors that may affect the course of therapy.
In working with involuntary clients, it is especially important to prepare them for
the process; doing so can go a long way toward increasing their cooperation and
involvement.
Tolerating Ambiguity
Many beginning therapists experience the anxiety of not seeing immediate results.
They ask themselves: “Am I really doing my client any good? Is the client perhaps
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 31
getting worse?” I hope you will learn to tolerate the ambiguity of not knowing for
sure whether your client is improving, at least during the initial sessions. Realize
that oftentimes clients may seemingly “get worse” before they show therapeutic
gains. Also, realize that the fruitful effects of the joint efforts of the therapist and
the client may manifest themselves after the conclusion of therapy.
Becoming Aware of Your Countertransference
Working with clients can affect you in personal ways, and your own vulnerabilities
and countertransference are bound to surface. If you are unaware of your personal
dynamics, you are in danger of being overwhelmed by a client’s emotional expe-
riences. Beginning counselors need to learn how to “let clients go” and not carry
around their problems until the next session. The most therapeutic thing is to be as
fully present as we are able to be during the therapy hour, but to let clients assume
the responsibility of their living and choosing outside of the session. If we become
lost in clients’ struggles and confusion, we cease being effective agents in helping
them find solutions to their problems. If we accept responsibility for our clients’
decisions, we are blocking rather than fostering their growth.
countertransference, defined broadly, includes any of our projections that
influence the way we perceive and react to a client. This phenomenon occurs when
we are triggered into emotional reactivity, when we respond defensively, or when
we lose our ability to be present in a relationship because our own issues become
involved. Recognizing the manifestations of our countertransference reactions is an
essential step in becoming competent counselors. Unless we are aware of our own
conflicts, needs, assets, and liabilities, we can use the therapy hour more for our own
purposes than for being available for our clients. Because it is not appropriate for us
to use clients’ time to work through our reactions to them, it is all the more impor-
tant that we be willing to work on ourselves in our own sessions with another thera-
pist, supervisor, or colleague. If we do not engage in this kind of self-exploration, we
increase the danger of losing ourselves in our clients and using them to meet our
unfulfilled needs.
The emotionally intense relationships we develop with clients can be expected to
tap into our own unresolved problem areas. Our clients’ stories and pain are bound
to have an impact on us; we will be affected by their stories and can express compas-
sion and empathy. However, we have to realize that it is their pain and not carry it
for them lest we become overwhelmed by their life stories and thus render ourselves
ineffective in working with them. Although we cannot completely free ourselves
from any traces of countertransference or ever fully resolve all personal conflicts
from the past, we can become aware of ways these realities influence our professional
work. Our personal therapy can be instrumental in enabling us to recognize and
manage our countertransference reactions. (This topic is explored in more depth in
Chapter 4.)
Developing a Sense of Humor
Therapy is a responsible endeavor, but it need not be deadly serious. Both clients and
counselors can enrich a relationship through humor. What a welcome relief when
we can admit that pain is not our exclusive domain. It is important to recognize
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32 C H A P T E R T W O
that laughter or humor does not mean that clients are not respected or work is not
being accomplished. There are times, of course, when laughter is used to cover up
anxiety or to escape from the experience of facing threatening material. The thera-
pist needs to distinguish between humor that distracts and humor that enhances
the situation.
Sharing Responsibility With the Client
You might struggle with finding the optimum balance in sharing responsibility
with your clients. One mistake is to assume full responsibility for the direction and
outcomes of therapy. This will lead to taking from your clients their rightful respon-
sibility of making their own decisions. It could also increase the likelihood of your
early burnout. Another mistake is for you to refuse to accept the responsibility for
making accurate assessments and designing appropriate treatment plans for your
clients. How responsibility will be shared should be addressed early in the course of
counseling. It is your responsibility to discuss specific matters such as length and
overall duration of the sessions, confidentiality, general goals, and methods used to
achieve goals. (Informed consent is discussed in Chapter 3.)
It is important to be alert to your clients’ efforts to get you to assume responsi-
bility for directing their lives. Many clients seek a “magic answer” as a way of escaping
the anxiety of making their own decisions. It is not your role to assume responsibil-
ity for directing your clients’ lives. Collaboratively designing contracts and home-
work assignments with your clients can be instrumental in your clients’ increasingly
finding direction within themselves. Perhaps the best measure of our effectiveness
as counselors is the degree to which clients are able to say to us, “I appreciate what
you have been to me, and because of your faith in me, and what you have taught me,
I am confident that I can go it alone.” Eventually, if we are effective, we will be out
of business!
Declining to Give Advice
Quite often clients who are suffering come to a therapy session seeking and even
demanding advice. They want more than direction; they want a wise counselor to
make a decision or resolve a problem for them. However, counseling should not be
confused with dispensing information. Therapists help clients discover their own
solutions and recognize their own freedom to act. Even if we, as therapists, were
able to resolve clients’ struggles for them, we would be fostering their dependence
on us. They would continually need to seek our counsel for every new twist in their
difficulties. Our task is to help clients make independent choices and accept the
consequences of their choices. The habitual practice of giving advice does not work
toward this end.
Defining Your Role as a Counselor
One of your challenges as a counselor will be to define and clarify your professional
role. As you read about the various theoretical orientations, you will discover the
many different roles of counselors that are related to the various theories. As a coun-
selor, you will likely be expected to function with a diverse range of roles.
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 33
From my perspective, the central function of counseling is to help clients rec-
ognize their own strengths, discover what is preventing them from using their
resources, and clarify what kind of life they want to live. Counseling is a process by
which clients are invited to look honestly at their behavior and make certain deci-
sions about how they want to modify the quality of their life. In this framework
counselors provide support and warmth, yet care enough to challenge clients so that
they will be able to take the actions necessary to bring about significant change.
You will need to consider that the professional roles you assume are likely to be
dependent on factors such as the client populations with whom you are working,
the specific therapeutic services you are providing, the particular stage of counsel-
ing, and the setting in which you work. Your role will not be defined once and for all.
You will have to reassess the nature of your professional commitments and redefine
your role at various times.
Learning to Use Techniques Appropriately
When you are at an impasse with a client, you may have a tendency to look for a
technique to get the sessions moving. Ideally, therapeutic techniques should evolve
from the therapeutic relationship and the material presented, and they should
enhance the client’s awareness or suggest possibilities for experimenting with new
behavior. It is imperative that you know the theoretical rationale for each technique
you use, and you need to be aware that the techniques are appropriate for the goals
of therapy. This does not mean that you need to restrict yourself to drawing on pro-
cedures within a single model; quite the contrary. However, it is important to avoid
using techniques in a hit-or-miss fashion, to fill time, to meet your own needs, or to
get things moving. Your methods need to be thoughtfully chosen as a way to help
clients make therapeutic progress.
Developing Your Own Counseling Style
Be aware of any tendency to copy the style of a supervisor, therapist, or some other
model. There is no one way to conduct therapy, and wide variations in approach can
be effective. You will inhibit your potential effectiveness in reaching others if you
attempt to imitate another therapist’s style or if you fit most of your behavior dur-
ing the session into the Procrustean bed of some expert’s theory. Your counseling
style will be influenced by your teachers, therapists, and supervisors, but don’t blur
your potential uniqueness by trying to imitate them. I advocate borrowing from
others, yet, at the same time, doing it in a way that is distinctive to you.
Maintaining Your Vitality as a Person and as a Professional
Ultimately, your single most important instrument is the person you are, and your
most powerful technique is your ability to model aliveness and realness. It is of para-
mount importance that we take care of ourselves, for how can we take care of others
if we are not taking care of ourselves? We need to work at dealing with those factors
that threaten to drain life from us and render us helpless. I encourage you to con-
sider how you can apply the theories you will be studying to enhance your life from
both a personal and a professional standpoint.
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34 C H A P T E R T W O
Learn to look within yourself to determine what choices you are making (and
not making) to keep yourself vital. If you are aware of the factors that sap your vital-
ity as a person, you are in a better position to prevent the condition known as profes-
sional burnout. You have considerable control over whether you become burned out
or not. You cannot always control stressful events, but you do have a great deal of
control over how you interpret and react to these events. It is important to realize
that you cannot continue to give and give while getting little in return. There is a
price to pay for always being available and for assuming responsibility over the lives
and destinies of others. Become attuned to the subtle signs of burnout rather than
waiting for a full-blown condition of emotional and physical exhaustion to set in.
You would be wise to develop your own strategy for keeping yourself alive personally
and professionally.
Self-monitoring is a crucial first step in self-care. If you make an honest inven-
tory of how well you are taking care of yourself in specific domains, you will have a
framework for deciding what you may want to change. By making periodic assess-
ments of the direction of your own life, you can determine whether you are living
the way you want to live. If not, decide what you are willing to actually do to make
changes occur. By being in tune with yourself, by having the experience of centered-
ness and solidness, and by feeling a sense of personal power, you have the founda-
tion for integrating your life experiences with your professional experiences. Such
an awareness can provide the basis for retaining your physical and psychological
vitality and for being an effective professional.
As counseling professionals, we tend to be caring people who are good at tak-
ing care of others, but often we do not treat ourselves with the same level of care.
Self-care is not a luxury; it is an ethical mandate. If we neglect to care for ourselves,
our clients will not be getting the best of us. If we are physically drained and psy-
chologically depleted, we will not have much to give to those with whom we work.
It is not possible to provide nourishment to our clients if we are not nourishing
ourselves.
Mental health professionals often comment that they do not have time to take
care of themselves. My question to them is, “Can you afford not to take care of your-
self?” To successfully meet the demands of our professional work, we must take care
of ourselves physically, psychologically, intellectually, socially, and spiritually. Ide-
ally, our self-care should mirror the care we provide for others. If we hope to have
the vitality and stamina required to stay focused on our professional goals, we need
to incorporate a wellness perspective into our daily living. Wellness is the result of
our conscious commitment to a way of life that leads to zest, peace, vitality, and
happiness.
Wellness and self-care are being given increased attention in professional jour-
nals and at professional conferences. When reading about self-care and wellness,
reflect on what you can do to put what you know into action. If you are interested in
learning more about therapist self-care, I highly recommend Leaving It at the Office: A
Guide to Psychotherapist Self-Care (Norcross & Guy, 2007) and Empathy Fatigue: Healing
the Mind, Body, and Spirit of Professional Counselors (Stebnicki, 2008). For more on the
topic of the counselor as a person and as a professional, see Creating Your Professional
Path: Lessons From My Journey (Corey, 2010).
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T H E C O u n s E l O R : P E R s O n A n D P R O f E s s I O n A l 35
Summary
One of the basic issues in the counseling profession concerns the significance of the
counselor as a person in the therapeutic relationship. In your professional work,
you are asking people to take an honest look at their lives and to make choices con-
cerning how they want to change, so it is critical that you do this in your own life.
Ask yourself questions such as “What do I personally have to offer others who are
struggling to find their way?” and “Am I doing in my own life what I may be urging
others to do?”
You can acquire an extensive theoretical and practical knowledge and can make
that knowledge available to your clients. But to every therapeutic session you also
bring yourself as a person. If you are to promote change in your clients, you need to
be open to change in your own life. This willingness to attempt to live in accordance
with what you teach and thus to be a positive model for your clients is what makes
you a “therapeutic person.”
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37
3Ethical Issues in Counseling Practice
1. Understand mandatory,
aspirational, and positive ethics.
2. Identify characteristics and
procedural steps of ethical
decision making.
3. Understand the right of informed
consent.
4. Articulate the dimensions of
confidentiality (privacy, privileged
communications, and exceptions).
5. Become familiar with the ethical
and legal aspects of using
technology.
6. Identify the major exceptions to
confidentiality.
7. Understand ethical issues from a
multicultural perspective.
8. Recognize when it is necessary to
modify techniques with diverse
clients.
9. Identify some key ethical issues in
assessment and diagnosis.
10. Understand how ethnic and
cultural factors can influence
assessment and diagnosis.
11. Compare arguments for and
against evidence-based practice.
12. Describe ethical issues related
to multiple relationships in
counseling practice.
13. Understand various perspectives
on multiple relationships.
14. Explain the differences between
a boundary crossing and a
boundary violation.
15. Understand how to manage
boundaries and risks associated
with using social media.
16. Explain what is involved in
becoming an ethical counselor.
L e a r n i n g O b j e c t i v e s
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38 C H A P T E R T H R E E
Introduction
This chapter introduces some of the ethical principles and issues that will be
a basic part of your professional practice. I hope to stimulate your thinking about
the importance of ethical practice so you will have a sound foundation for making
ethical decisions. Topics addressed include balancing clients’ needs against your
own needs, ways of making good ethical decisions, educating clients about their
rights, parameters of confidentiality, ethical concerns in counseling diverse client
populations, ethical issues involving diagnosis, evidence-based practice, and dealing
with multiple relationships and managing boundaries.
Students sometimes think of ethics merely as a list of rules and prohibitions
that result in sanctions and malpractice actions if practitioners do not follow them.
You will learn that being an ethical practitioners is far more complex than a set of
rules. Mandatory ethics involves a level of ethical functioning at the minimum level
of professional practice. In contrast, aspirational ethics focuses on doing what is in
the best interests of clients. Functioning at the aspirational level involves the high-
est standards of thinking and conduct. Aspirational practice requires counselors to
do more than simply meet the letter of the ethics code. It entails understanding the
spirit of the code and the principles on which the code is based. Fear-based ethics does
not constitute sound ethical practice. Ethics is more than a list of things to avoid
for fear of punishment. Strive to work toward concern-based ethics, and think about
how you can become the best practitioner possible (Corey, Corey, Corey, & Callanan,
2015). Positive ethics is an approach taken by practitioners who want to do their
best for clients rather than simply meet minimum standards to stay out of trouble
(Knapp & VandeCreek, 2006).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 3, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Putting Clients’ Needs Before Your Own
As counselors we cannot always keep our personal needs completely separate from
our relationships with clients. Ethically, it is essential that we become aware of our
own needs, areas of unfinished business, potential personal problems, and espe-
cially our sources of countertransference. We need to realize how such factors could
interfere with effectively and ethically serving our clients.
Our professional relationships with our clients exist for their benefit. A use-
ful question to frequently ask yourself is this: “Whose needs are being met in this
relationship, my client’s or my own?” It takes considerable professional maturity to
make an honest appraisal of how your behavior affects your clients. It is not unethi-
cal for us to meet our personal needs through our professional work, but it is essen-
tial that these needs be kept in perspective. An ethical problem exists when we meet
our needs, in either obvious or subtle ways, at the expense of our clients’ needs. It is
crucial that we avoid exploiting or harming clients.
We all have certain blind spots and distortions of reality. As helping profession-
als, we must actively work toward expanding our self-awareness and learn to recognize
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 39
our areas of prejudice and vulnerability. If we are aware of our personal problems and
are willing to work through them, there is less chance that we will project them onto
clients. If certain problem areas surface and old conflicts become reactivated, we have
an ethical obligation to do whatever it takes to avoid harming our clients.
We must also examine other, less obviously harmful personal needs that can
get in the way of creating growth-producing relationships, such as the need for con-
trol and power; the inordinate need to be nurturing; the need to change others in
the direction of our own values; the need for feeling adequate, particularly when it
becomes overly important that the client confirm our competence; and the need
to be respected and appreciated. It is crucial that we do not meet our needs at the
expense of our clients. For an expanded discussion of this topic, see M. Corey and
Corey (2016, chap. 1).
Ethical Decision Making
The ready-made answers to ethical dilemmas provided by professional
organizations typically contain only broad guidelines for responsible practice. In
practice, you will have to apply the ethics codes of your profession to the many
practical problems you face. Professionals are expected to exercise prudent judg-
ment when it comes to interpreting and applying ethical principles to specific situ-
ations. Although you are responsible for making ethical decisions, you do not have
to do so alone. Learn about the resources available to you. Consult with colleagues,
keep yourself informed about laws affecting your practice, keep up to date in your
specialty field, stay abreast of developments in ethical practice, reflect on the impact
your values have on your practice, and be willing to engage in honest self-examina-
tion. You should also be aware of the consequences of practicing in ways that are
not sanctioned by organizations of which you are a member or the state in which
you are licensed to practice.
The Role of Ethics Codes as a Catalyst for Improving Practice
Professional codes of ethics serve a number of purposes. They educate counseling
practitioners and the general public about the responsibilities of the profession.
They provide a basis for accountability, and protect clients from unethical practices.
Perhaps most important, ethics codes provide a basis for reflecting on and improv-
ing your professional practice. Self-monitoring is a better route for professionals to
take than being policed by an outside agency (Herlihy & Corey, 2015a).
From my perspective, an unfortunate recent trend is for ethics codes to increas-
ingly take on legalistic, rule-based dimensions. Being an ethical practitioner involves
far more than following a list of rules. Practitioners anxious to avoid any litigation
may gear their practices mainly toward fulfilling legal minimums. If we are too con-
cerned with being sued, it is unlikely that we will be very creative or effective in our
work. It makes sense to be aware of the legal aspects of practice and to know and
practice risk-management strategies, but we should not lose sight of what is best for
our clients. One of the best ways to prevent being sued for malpractice is to demon-
strate respect for clients, keep client welfare as a central concern, and practice within
the framework of professional codes.
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40 C H A P T E R T H R E E
No code of ethics can delineate what would be the appropriate or best course of
action in each problematic situation a professional will face. In my view, ethics codes
are best used as guidelines to formulate sound reasoning and serve practitioners in
making the best judgments possible. A number of professional organizations and
their websites are listed near the end of the chapter; each has its own code of ethics,
which you can access through its website. Compare your professional organization’s
code of ethics to several others to understand their similarities and differences.
Some Steps in Making Ethical Decisions
Most models for ethical decision making focus on the application of principles to
ethical dilemmas. My colleagues and I have identified a series of procedural steps
to help you think through ethical problems when using these principles (see Corey,
Corey, Corey, & Callanan, 2015):
�� Identify the problem or dilemma. Gather information that will shed
light on the nature of the problem. This will help you decide whether
the problem is mainly ethical, legal, professional, clinical, or moral.
�� Identify the potential issues. Evaluate the rights, responsibilities, and
welfare of all those who are involved in the situation.
�� Look at the relevant ethics codes for general guidance on the matter.
Consider whether your own values and ethics are consistent with or in
conflict with the relevant guidelines.
�� Consider the applicable laws and regulations, and determine how they
may have a bearing on an ethical dilemma.
�� Seek consultation from more than one source to obtain various per-
spectives on the dilemma, and document in the client’s record the
suggestions you received from this consultation.
�� Brainstorm various possible courses of action. Continue discussing
options with other professionals. Include the client in this process of
considering options for action. Again, document the nature of this
discussion with your client.
�� Enumerate the consequences of various decisions, and reflect on the
implications of each course of action for your client.
�� Decide on what appears to be the best possible course of action.
Once the course of action has been implemented, follow up to evalu-
ate the outcomes and to determine whether further action is neces-
sary. Document the reasons for the actions you took as well as your
evaluation measures.
In reasoning through any ethical dilemma, there is rarely just one course of action
to follow, and practitioners may make different decisions. The more subtle the
ethical dilemma, the more complex and demanding the decision-making process.
Professional maturity implies that you are open to questioning and discussing
your quandaries with colleagues. In seeking consultation, it is generally possible to
protect the identity of your client and still get useful input that is critical to making
sound ethical decisions. Because ethics codes do not make decisions for you, it is a
good practice to demonstrate a willingness to explore various aspects of a problem,
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 41
raise questions, discuss ethical concerns with others, and continually clarify your
values and examine your motivations. To the degree that it is possible, include the
client in all phases of the ethical decision-making process. Again, it is essential to
document how you included your client as well as the steps you took to ensure
ethical practice.
The Right of Informed Consent
Regardless of your theoretical framework, informed consent is an ethical
and legal requirement that is an integral part of the therapeutic process. It also
establishes a basic foundation for creating a working alliance and a collabora-
tive partnership between the client and the therapist. informed consent involves
the right of clients to be informed about their therapy and to make autonomous
decisions pertaining to it. Providing clients with information they need to make
informed choices tends to promote the active cooperation of clients in their coun-
seling plan. By educating your clients about their rights and responsibilities, you are
both empowering them and building a trusting relationship with them. Seen in this
light, informed consent is something far broader than simply making sure clients
sign the appropriate forms. It is a positive approach that helps clients become active
partners and true collaborators in their therapy.
Some aspects of the informed consent process include the general goals of coun-
seling, the responsibilities of the counselor toward the client, the responsibilities of
clients, limitations of and exceptions to confidentiality, legal and ethical parameters
that could define the relationship, the qualifications and background of the prac-
titioner, the fees involved, the services the client can expect, and the approximate
length of the therapeutic process. Further areas might include the benefits of coun-
seling, the risks involved, and the possibility that the client’s case will be discussed
with the therapist’s colleagues or supervisors.
There are a host of ways to violate a client’s privacy through the inappropriate
use of various forms of modern-day technology. Most of us have become accustomed
to relying on technology, and we need to give careful thought to the subtle ways cli-
ent privacy can be compromised. As a part of the informed consent process, it is
wise to discuss the potential privacy problems of using a wide range of technology
and to take preventive measures to protect both you and your clients. For example,
clients and counselors should carefully consider privacy issues before agreeing to
send e-mail messages to clients’ workplace or home. A good policy is to limit e-mail
exchanges to basic information such as appointment times.
Educating the client begins with the initial counseling session, and this process
will continue for the duration of counseling. The challenge of fulfilling the spirit of
informed consent is to strike a balance between giving clients too much information
and giving them too little. For example, it is too late to tell minors that you intend
to consult with their parents after they have disclosed that they are considering an
abortion. Young clients have a right to know about the limitations of confidentiality
before they make such highly personal disclosures. Clients can be overwhelmed, how-
ever, if counselors go into too much detail initially about the interventions they are
likely to make. It takes both intuition and skill for practitioners to strike a balance.
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42 C H A P T E R T H R E E
Informed consent in counseling can be provided in written form, orally, or some
combination of both. If it is done orally, therapists must make an entry in the client’s
clinical record documenting the nature and extent of informed consent (Nagy, 2011).
It is a good idea to provide basic information about the therapy process in writing,
as well as to discuss with clients topics that will enable them to get the maximum
benefit from their counseling experience. Written information protects both clients
and therapists and enables clients to think about the information and bring up ques-
tions at the following session. For a more complete discussion of informed consent
and client rights, see Issues and Ethics in the Helping Professions (Corey, Corey, Corey, &
Callanan, 2015, chap. 5), The Counselor and the Law: A Guide to Legal and Ethical Practice
(Wheeler & Bertram, 2015, chap. 2), Ethical, Legal, and Professional Issues in Counseling
(Remley & Herlihy, 2016), and Essential Ethics for Psychologists (Nagy, 2011, chap. 5).
Dimensions of Confidentiality
Confidentiality and privileged communication are two related but some-
what different concepts. Both of these concepts are rooted in a client’s right to pri-
vacy. confidentiality is an ethical concept, and in most states it is the legal duty of
therapists not to disclose information about a client. Privileged communication
is a legal concept that protects clients from having their confidential communications
revealed in court without their permission (Herlihy & Corey, 2015a). All states have
enacted into law some form of psychotherapist–client privilege, but the specifics
of this privilege vary from state to state. These laws ensure that disclosures clients
make in therapy will be protected from exposure by therapists in legal proceedings.
Generally speaking, the legal concept of privileged communication does not apply
to group counseling, couples counseling, family therapy, child and adolescent ther-
apy, or whenever there are more than two people in the room.
Confidentiality is central to developing a trusting and productive client–thera-
pist relationship. Because no genuine therapy can occur unless clients trust in the
privacy of their revelations to their therapists, professionals have the responsibility
to define the degree of confidentiality that can be promised. Counselors have an
ethical and legal responsibility to discuss the nature and purpose of confidentiality
with their clients early in the counseling process. In addition, clients have a right to
know that their therapist may be discussing certain details of the relationship with
a supervisor or a colleague.
Ethical Concerns with the Use of Technology
Issues pertaining to confidentiality and privacy can become more com-
plicated when technology is involved. Section H of the ACA Code of Ethics (2014)
contains a new set of standards with regard to the use of technology, relationships
established through computer-mediated communication, and social media as a
delivery platform. Major subsections address competency to provide services and
the laws associated with distance counseling, components of informed consent and
security (confidentiality and its limitations), client verification, the distance coun-
seling relationship (access, accessibility, and professional boundaries), maintenance
of records, accessibility of websites, and the use of social media (Jencius, 2015).
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 43
Exceptions to Confidentiality and Privileged Communication
Although most counselors agree on the essential value of confidentiality,
they realize that other obligations may override this pledge. There are times when
confidential information must be divulged, and there are many instances in which
keeping or breaking confidentiality becomes a cloudy issue. In determining when
to breach confidentiality, therapists must consider the requirements of the law, the
institution in which they work, and the clientele they serve. Because these circum-
stances are frequently not clearly defined by accepted ethics codes, counselors must
exercise professional judgment.
Whenever counselors are not clear about their obligations regarding confiden-
tiality or privileged communication, it is critical to seek consultation and to docu-
ment these discussions. Remley and Herlihy (2016) identify at least 15 exceptions
to confidentiality and privileged communication. There is a legal requirement to
break confidentiality in cases involving child abuse, abuse of the elderly, abuse of
dependent adults, and danger to self or others. All mental health practitioners and
interns need to be aware of their duty to report in these situations and to know the
limitations of confidentiality. Here are some other circumstances in which informa-
tion must legally be reported by counselors:
�� When the therapist believes a client under the age of 16 is the victim of
incest, rape, child abuse, or some other crime
�� When the therapist determines that the client needs hospitalization
�� When information is made an issue in a court action
�� When clients request that their records be released to them or to a third
party
In general, the counselor’s primary obligation is to protect client disclosures as a
vital part of the therapeutic relationship. Informing clients about the limits of con-
fidentiality does not necessarily inhibit successful counseling.
For a more complete discussion of confidentiality, see Issues and Ethics in the Help-
ing Professions (Corey, Corey, Corey, & Callanan, 2015, chap. 6), Essential Ethics for
Psychologists (Nagy, 2011, chap. 6), The Counselor and the Law: A Guide to Legal and Ethical
Practice (Wheeler & Bertram, 2015, chap. 5), and Ethical, Legal, and Professional Issues in
Counseling (Remley & Herlihy, 2016, chap. 5).
Ethical Issues From a Multicultural Perspective
Ethical practice requires that we take the client’s cultural context into
account in counseling practice. In this section we look at how it is possible for
practitioners to practice unethically if they do not address cultural differences in
counseling practice.
Are Current Theories Adequate in Working With Culturally
Diverse Populations?
I believe current theories can be, and need to be, expanded to include a multicul-
tural perspective. Assumptions made about mental health, optimum human
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44 C H A P T E R T H R E E
development, the nature of psychopathology, and the nature of effective treatment
may have little relevance for some clients. For traditional theories to be relevant in a
multicultural and diverse society, they must incorporate an interactive person-in-
the-environment focus. That is, individuals are best understood by taking into con-
sideration salient cultural and environmental variables. It is essential for therapists
to create therapeutic strategies that are congruent with the range of values and
behaviors that are characteristic of a pluralistic society.
Is Counseling Culture-Bound?
Historically, therapists have relied on Western therapeutic models to guide
their practice and to conceptualize problems that clients present in mental health
settings. Western models of counseling have some limitations when applied to spe-
cial populations and cultural groups such as Asian and Pacific Islanders, Latinos,
Native Americans, and African Americans. Multicultural writers have asserted that
theories of counseling and psychotherapy represent different worldviews, each
with its own values, biases, and assumptions about human behavior. Some of these
approaches may not be applicable to clients from different racial, ethnic, and cul-
tural backgrounds. Methods often need to be modified when working with clients
from diverse cultural backgrounds.
Contemporary therapy approaches are grounded on a core set of values, which
are neither value-neutral nor applicable to all cultures. For example, the values of
individual choice and autonomy are not universal. In some cultures the key values
are collectivist, and primary consideration is given to what is good for the group.
Regardless of the therapist’s orientation, it is crucial to listen to clients and deter-
mine why they are seeking help and how best to deliver the help that is appropriate
for them. Competent therapists understand themselves as social and cultural beings
and possess at least a minimum level of knowledge and skill that they can bring to
bear on any counseling situation. These practitioners understand what their clients
need and avoid forcing clients into a preconceived mold.
Cultural diversity is a fact of life in our world. To the extent that counselors are
focused on the values of the dominant culture and insensitive to variations among
groups and individuals, they are at risk for practicing unethically (Barnett & John-
son, 2015). Counselors need to understand and accept clients who have a different
set of assumptions about life, and they need to be alert to the possibility of imposing
their own worldview. In working with clients from different cultural backgrounds
and life experiences, it is important that counselors resist making value judgments
for them. It is essential to be mindful of diversity and social justice issues if we are to
practice ethically and effectively (Chung & Bemak, 2012; Lee, 2015).
Focusing on Both Individual and Environmental Factors
A theoretical orientation provides practitioners with a map to guide them in a pro-
ductive direction with their clients. It is hoped that the theory orients them but
does not control what they attend to in the therapeutic venture. Counselors who
operate from a multicultural framework also have certain assumptions and a focus
that guides their practice. They view individuals in the context of the family and the
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 45
culture, and their aim is to facilitate social action that will lead to change within
the client’s community rather than merely increasing the individual’s insight. Both
multicultural practitioners and feminist therapists maintain that therapeutic prac-
tice will be effective only to the extent that interventions are tailored toward social
action aimed at changing those factors that are creating the client’s problem rather
than blaming the client for his or her condition (Chung & Bemak, 2012). These top-
ics are developed in more detail in later chapters.
An adequate theory of counseling does deal with the social and cultural factors
of an individual’s problems. However, there is something to be said for helping cli-
ents deal with their response to environmental realities. Counselors may well be at a
loss in trying to bring about social change when they are sitting with a client who is
in pain because of social injustice. By using techniques from many of the traditional
therapies, counselors can help clients increase their awareness of their options in
dealing with barriers and struggles. However, it is essential to focus on both indi-
vidual and social factors if change is to occur, as the feminist, postmodern, and fam-
ily systems approaches to therapy teach us. Indeed, the person-in-the-environment
perspective acknowledges this interactive reality. For a more detailed treatment of
the ethical issues in multicultural counseling, see Chung and Bemak (2012), Corey,
Corey, Corey, and Callanan (2015, chap. 4), and Lee (2013).
Ethical Issues in the Assessment Process
Both clinical and ethical issues are associated with the use of assessment
and diagnostic procedures. As you will see when you study the various theories of
counseling, some approaches place heavy emphasis on the role of assessment as a
prelude to the treatment process; other approaches find assessment less useful in
this regard.
The Role of Assessment and Diagnosis in Counseling
Assessment and diagnosis are integrally related to the practice of counseling and
psychotherapy, and both are often viewed as essential for planning treatment. For
some approaches, a comprehensive assessment of the client is the initial step in the
therapeutic process. The rationale is that specific counseling goals cannot be for-
mulated and appropriate treatment strategies cannot be designed until a client’s
past and present functioning is understood. Regardless of their theoretical orienta-
tion, therapists need to engage in assessment, which is generally an ongoing part of
the therapeutic process. This assessment may be subject to revision as the clinician
gathers further data during therapy sessions. Some practitioners consider assessment
as a part of the process that leads to a formal diagnosis.
assessment consists of evaluating the relevant factors in a client’s life to iden-
tify themes for further exploration in the counseling process. Diagnosis, which is
sometimes part of the assessment process, consists of identifying a specific mental
disorder based on a pattern of symptoms. Both assessment and diagnosis can be
understood as providing direction for the treatment process.
Diagnosis may include an explanation of the causes of the client’s difficulties, an
account of how these problems developed over time, a classification of any disorders,
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46 C H A P T E R T H R E E
a specification of preferred treatment procedure, and an estimate of the chances for
a successful resolution. The purpose of diagnosis in counseling and psychotherapy
is to identify disruptions in a client’s present behavior and lifestyle. Once problem
areas are clearly identified, the counselor and client are able to establish the goals of
the therapy process, and then a treatment plan can be tailored to the unique needs
of the client. A diagnosis provides a working hypothesis that guides the practitioner
in understanding the client. The therapy sessions provide useful clues about the
nature of the client’s problems. Thus diagnosis begins with the intake interview and
continues throughout the duration of therapy.
The classic book for guiding practitioners in making diagnostic assessments
is the fifth edition of the American Psychiatric Association’s (2013) Diagnostic and
Statistical Manual of Mental Disorders (also known as the DSM-5). Clinicians who work
in community mental health agencies, private practice, and other human service
settings are generally expected to assess client problems within this framework. This
manual advises practitioners that it represents only an initial step in a comprehen-
sive evaluation and that it is necessary to gain information about the person being
evaluated beyond that required for a DSM-5 diagnosis.
Sme clinicians view diagnosis as central to the counseling process, but others
view it as unnecessary, as a detriment, or as discriminatory against ethnic minorities
and women. As you will see when you study the therapeutic models in this book,
some approaches do not use diagnosis as a precursor to treatment.
Considering Ethnic and Cultural Factors in Assessment and Diagnosis
A danger of the diagnostic approach is the possible failure of counselors to consider
ethnic and cultural factors in certain patterns of behavior. The DSM-5 emphasizes
the importance of being aware of unintentional bias and keeping an open mind
to the presence of distinctive ethnic and cultural patterns that could influence
the diagnostic process. Unless cultural variables are considered, some clients may
be subjected to erroneous diagnoses. Certain behaviors and personality styles
may be labeled neurotic or deviant simply because they are not characteristic of
the dominant culture. Counselors who work with diverse client populations may
erroneously conclude that a client is repressed, inhibited, passive, and unmotivated,
all of which are seen as undesirable by Western standards.
The DSM-5 is based on a medical model of mental illness that defines problems
as residing with the individual rather than in society. It does not take into account
the political, economic, social, and cultural factors in the lives of clients, which may
play a significant role in the problems of clients. The DSM system tends to patholo-
gize clients, perpetuating the oppression of clients from diverse groups (Remley &
Herlihy, 2016). Barnett and Johnson (2015) suggest that practitioners give careful
consideration before rendering a diagnosis and take into consideration the reali-
ties of discrimination, oppression, and racism in society and in the mental health
disciplines.
Assessment and Diagnosis From Various Theoretical Perspectives The theory
from which you operate influences your thinking about the use of a diagnostic
framework in your therapeutic practice. Many practitioners who use the cognitive
behavioral approaches and the medical model place heavy emphasis on the role
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 47
of assessment as a prelude to the treatment process. The rationale is that specific
therapy goals cannot be designed until a clear picture emerges of the client’s past
and present functioning. In addition, progress, change, improvement, or success
may be difficult to evaluate without an initial assessment. Counselors who base
their practice on the relationship-oriented approaches tend to view the process
of assessment and diagnosis as external to the immediacy of the client–counselor
relationship, impeding their understanding of the subjective world of the client. As
you will see in Chapter 12, feminist therapists contend that traditional diagnostic
practices are often oppressive and that such practices are based on a White, male-
centered, Western notion of mental health and mental illness. Both the feminist
perspective and the postmodern approaches (Chapter 13) charge that these
diagnoses ignore societal contexts. Therapists with a feminist, social constructionist,
solution-focused, or narrative therapy orientation challenge many DSM-5 diagnoses.
However, these practitioners do make assessments and draw conclusions about
client problems and strengths. Regardless of the particular theory espoused by a
therapist, both clinical and ethical issues are associated with the use of assessment
procedures and possibly a diagnosis as part of a treatment plan.
A Commentary on Assessment and Diagnosis Most practitioners and many
writers in the field consider assessment and diagnosis to be a continuing process
that focuses on understanding the client. The collaborative perspective that involves
the client as an active participant in the therapy process implies that both the
therapist and the client are engaged in a search-and-discovery process from the first
session to the last. Even though some practitioners may avoid formal diagnostic
procedures and terminology, making tentative hypotheses and sharing them with
clients throughout the process is a form of ongoing diagnosis. This perspective on
assessment and diagnosis is consistent with the principles of feminist therapy, an
approach that is critical of traditional diagnostic procedures.
Ethical dilemmas may be created when diagnosis is done strictly for insur-
ance purposes, which often entails arbitrarily assigning a client to a diagnostic
classification. However, it is a clinical, legal, and ethical obligation of therapists
to screen clients for life-threatening problems such as organic disorders, schizo-
phrenia, bipolar disorder, and suicidal types of depression. Students need to
learn the clinical skills necessary to do this type of screening, which is a form of
diagnostic thinking.
It is essential to assess the whole person, which includes assessing dimensions
of mind, body, and spirit. Therapists need to take into account the biological pro-
cesses as possible underlying factors of psychological symptoms and work closely
with physicians. Clients’ values can be instrumental resources in the search for solu-
tions to their problems, and spiritual and religious values often illuminate client
concerns.
For a more detailed discussion of assessment and diagnosis in counseling prac-
tice as it is applied to a single case, consult Case Approach to Counseling and Psycho-
therapy (Corey, 2013b), in which theorists from 12 different theoretical orientations
share their diagnostic perspectives on the case of Ruth. For a comprehensive review
of the changes in the DSM-5, see DSM-5 Learning Companion for Counselors (Dailey,
Gill, Karl, & Minton, 2014).
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48 C H A P T E R T H R E E
Ethical Aspects of Evidence-Based Practice
Mental health practitioners are faced with the task of choosing the best
interventions with a particular client. For many practitioners this choice is based on
their theoretical orientation. In recent years, however, a shift has occurred toward
promoting the use of specific interventions for specific problems or diagnoses based
on empirically supported treatments (APA Presidential Task Force on Evidence-
based Practice, 2006; Cukrowicz et al., 2005; Deegear & Lawson, 2003; Edwards,
Dattilio, & Bromley, 2004).
This trend toward specific, empirically supported treatment is referred to as
evidence-based practice (ebP): “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture, and preferences”
(APA Presidential Task Force on Evidence-based Practice, 2006, p. 273). Increas-
ingly, those practitioners who work in a behavioral health care system must cope
with the challenges associated with evidence-based practice. Norcross, Hogan, and
Koocher (2008) advocate for inclusive evidence-based practices that incorporate the
three pillars of EBP: (1) looking for the best available research, (2) relying on clinical
expertise, and (3) taking into consideration the client’s characteristics, culture, and
preferences.
Many aspects of treatment—the therapy relationship, the therapist’s personality
and therapeutic style, the client, and environmental factors—are vital contributors
to the success of psychotherapy. Evidence-based practices tend to emphasize only
one of these aspects—interventions based on the best available research. The central
aim of evidence-based practice is to require psychotherapists to base their practice
on techniques that have empirical evidence to support their efficacy. Research stud-
ies empirically analyze the most effective and efficient treatments, which then can be
widely implemented in clinical practice (Norcross, Beutler, & Levant, 2006).
In many mental health settings, clinicians are pressured to use interventions
that are both brief and standardized. In such settings, treatments are operational-
ized by reliance on a treatment manual that identifies what is to be done in each
therapy session and how many sessions will be required (Edwards et al., 2004). Many
practitioners believe this approach is mechanistic and does not take into full consid-
eration the relational dimensions of the psychotherapy process and individual vari-
ability. Indeed, relying exclusively on standardized treatments for specific problems
may raise another set of ethical concerns because the reliability and validity of these
empirically based techniques is questionable.
Human change is complex and difficult to measure beyond such a simplis-
tic level that the change may be meaningless. Furthermore, not all clients come to
therapy with clearly defined psychological disorders. Many clients have existential
concerns that do not fit with any diagnostic category and do not lend themselves to
clearly specified symptom-based outcomes. EBP may have something to offer mental
health professionals who work with individuals with specific emotional, cognitive,
and behavioral disorders, but it does not have a great deal to offer practitioners work-
ing with individuals who want to pursue more meaning and fulfillment in their lives.
Norcross and his colleagues (2006) contend that the call for accountability
in mental health care is here to stay and that all mental health professionals are
challenged by the mandate to demonstrate the efficiency, efficacy, and safety of the
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 49
services they provide. They emphasize that the overarching goal of EBP is to enhance
the effectiveness of client services and to improve public health and warn that men-
tal health professionals need to take a proactive stance to make sure this goal is kept
in focus. They realize there is potential for misuse and abuse by third-party pay-
ers who could selectively use research findings as cost-containment measures rather
than ways of improving the quality of services delivered.
For further reading on the topic of evidence-based practice, I recommend
Clinician’s Guide to Evidence-based Practice (Norcross et al., 2008).
Managing Multiple Relationships in Counseling Practice
Dual or multiple relationships, either sexual or nonsexual, occur when
counselors assume two (or more) roles simultaneously or sequentially with a client.
This may involve assuming more than one professional role or combining profes-
sional and nonprofessional roles. The term multiple relationship is more often used
than the term dual relationship because of the complexities involved in these relation-
ships, but both terms appear in various professional codes of ethics, and the ACA
(2014) uses the term nonprofessional relationships. In this section I use the broader
term of multiple relationships to encompass both dual relationships and nonprofes-
sional relationships.
When clinicians blend their professional relationship with another kind of rela-
tionship with a client, ethical concerns must be considered. Many forms of non-
professional interactions or nonsexual multiple relationships pose a challenge to
practitioners. Some examples of nonsexual dual or multiple relationships are com-
bining the roles of teacher and therapist or of supervisor and therapist; bartering
for goods or therapeutic services; borrowing money from a client; providing ther-
apy to a friend, an employee, or a relative; engaging in a social relationship with a
client; accepting an expensive gift from a client; or going into a business venture
with a client. Some multiple relationships are clearly exploitative and do serious
harm both to the client and to the professional. For example, becoming emotion-
ally or sexually involved with a current client is clearly unethical, unprofessional, and
illegal. Sexual involvement with a former client is unwise, can be exploitative, and is
generally considered unethical.
Because nonsexual multiple relationships are necessarily complex and multi-
dimensional, there are few simple and absolute answers to resolve them. It is not
always possible to play a single role in your work as a counselor, nor is it always desir-
able. You may have to deal with managing multiple roles, regardless of the setting in
which you work or the client population you serve. It is a wise practice to give careful
thought to the complexities of multiple roles and relationships before embroiling
yourself in ethically questionable situations.
Ethical reasoning and judgment come into play when ethics codes are applied
to specific situations. The ACA Code of Ethics (ACA, 2014) makes it clear that counsel-
ing professionals must learn how to manage multiple roles and responsibilities in an
ethical way. This entails dealing effectively with the power differential that is inherent
in counseling relationships and training relationships, balancing boundary issues,
addressing nonprofessional relationships, and striving to avoid using power in ways
that might cause harm to clients, students, or supervisees (Herlihy & Corey, 2015b).
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50 C H A P T E R T H R E E
Although multiple relationships do carry inherent risks, it is a mistake to con-
clude that these relationships are always unethical and necessarily lead to harm and
exploitation. Some of these relationships can be beneficial to clients if they are
implemented thoughtfully and with integrity (Zur, 2007). An excellent resource on
the ethical and clinical dimensions of multiple relationships is Boundaries in Psycho-
therapy: Ethical and Clinical Explorations (Zur, 2007).
Perspectives on Multiple Relationships
What makes multiple relationships so problematic? Herlihy and Corey
(2015b) contend that some of the problematic aspects of engaging in multiple
relationships are that they are pervasive; they can be difficult to recognize; they are
unavoidable at times; they are potentially harmful, but not necessarily always harm-
ful; they can be beneficial; and they are the subject of conflicting advice from various
experts. A review of the literature reveals that dual and multiple relationships are
hotly debated. Except for sexual intimacy with current clients, which is unequivo-
cally unethical, there is not much consensus regarding the appropriate way to deal
with multiple relationships.
Some of the codes of the professional organizations advise against forming
multiple relationships, mainly because of the potential for misusing power, exploit-
ing the client, and impairing objectivity. When multiple relationships exploit clients,
or have significant potential to harm clients, they are unethical. The ethics codes do
not mandate avoidance of all such relationships, however; nor do the codes imply
that nonsexual multiple relationships are unethical. The current focus of ethics
codes is to remain alert to the possibilities of harm to clients and to develop safe-
guard to protect clients. Although codes can provide some general guidelines, good
judgment, the willingness to reflect on one’s practices, and being aware of one’s
motivations are critical dimensions of an ethical practitioner. It bears repeating that
multiple relationship issues cannot be resolved with ethics codes alone; counselors
must think through all of the ethical and clinical dimensions involved in a wide
range of boundary concerns.
A consensus of many writers is that multiple relationships are inevitable and
unavoidable in some situations and that a global prohibition is not a realistic answer.
Because interpersonal boundaries are not static but undergo redefinition over time, the
challenge for practitioners is to learn how to manage boundary fluctuations and to deal
effectively with overlapping roles (Herlihy & Corey, 2015b). One key to learning how to
manage multiple relationships is to think of ways to minimize the risks involved.
Ways of Minimizing Risk In determining whether to proceed with a multiple
relationship, it is critical to consider whether the potential benefit to the client of
such a relationship outweighs its potential harm. Some relationships may have more
potential benefits to clients than potential risks. It is your responsibility to develop
safeguards aimed at reducing the potential for negative consequences. Herlihy and
Corey (2015b) identify the following guidelines:
�� Set healthy boundaries early in the therapeutic relationship. Informed
consent is essential from the beginning and throughout the therapy
process.
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 51
�� Involve clients in ongoing discussions and in the decision-making pro-
cess, and document your discussions. Discuss with your clients what
you expect of them and what they can expect of you.
�� Consult with fellow professionals as a way to maintain objectivity and
identify unanticipated difficulties. Realize that you don’t need to make
a decision alone.
�� When multiple relationships are potentially problematic, or when
the risk for harm is high, it is always wise to work under supervision.
Document the nature of this supervision and any actions you take in
your records.
�� Self-monitoring is critical throughout the process. Ask yourself whose
needs are being met and examine your motivations for considering
becoming involved in a dual or multiple relationship.
In working through a multiple relationship concern, it is best to begin by ascer-
taining whether such a relationship can be avoided. Nagy (2011) points out that
multiple relationships cannot always be avoided, especially in small towns. Nor
should every multiple relationship be considered unethical. However, when a thera-
pist’s objectivity and competence are compromised, the therapist may find that per-
sonal needs surface and diminish the quality of the therapist’s professional work.
Sometimes nonprofessional interactions are avoidable and your involvement would
put the client needlessly at risk. In other cases multiple relationships are unavoid-
able. One way of dealing with any potential problems is to adopt a policy of com-
pletely avoiding any kind of nonprofessional interaction. As a general guideline,
Nagy (2011) recommends avoiding multiple relationships to the extent this is pos-
sible. Therapists should document precautions taken to protect clients when such
relationships are unavoidable. Another alternative is to deal with each dilemma as it
develops, making full use of informed consent and at the same time seeking consul-
tation and supervision in dealing with the situation. This second alternative includes
a professional requirement for self-monitoring. It is one of the hallmarks of profes-
sionalism to be willing to grapple with these ethical complexities of day-to-day
practice.
Establishing Personal and Professional Boundaries Establishing and
maintaining consistent yet flexible boundaries is necessary if you are to effectively
counsel clients. If you have difficulty establishing and maintaining boundaries in
your personal life, you are likely to find that you will have difficulty when it comes
to managing boundaries in your professional life. Developing appropriate and
effective boundaries in your counseling practice is the first step to learning how
to manage multiple relationships. There is a relationship between developing
appropriate boundaries in the personal and professional realms. If you are successful
in establishing boundaries in various aspects of your personal life, you have a good
foundation for creating sound boundaries with clients.
One important aspect of maintaining appropriate professional boundaries is
to recognize boundary crossings and prevent them from becoming boundary
violations. A boundary crossing is a departure from a commonly accepted practice
that could potentially benefit a client. For example, attending the wedding of a client
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52 C H A P T E R T H R E E
may be extending a boundary, but it could be beneficial for the client. In contrast, a
boundary violation is a serious breach that harms the client and is therefore uneth-
ical. A boundary violation is a boundary crossing that takes the practitioner out of
the professional role, generally involves exploitation, and results in harm to a client
(Gutheil & Brodsky, 2008). Flexible boundaries can be useful in the counseling pro-
cess when applied ethically. Some boundary crossings pose no ethical problems and
may enhance the counseling relationship. Other boundary crossings may lead to a
pattern of blurred professional roles and become problematic.
Social Media and Boundaries It is not unusual for a counselor to
receive a “friend request” from a client or former client. Facebook and other social
media sites raise many ethical concerns for counselors regarding boundaries, dual
relationships, confidentiality, and privacy. One possibility is to set up two distinct
Facebook pages, one for professional use and the other for personal use. Spotts-De
Lazzer (2012) believes practitioners will have to translate and maintain traditional
ethics when it comes to social media and offers these recommendations:
�� Limit what is shared online.
�� Include clear and thorough social networking policies as part of the
informed consent process.
�� Regularly update protective settings because social media providers
often change their privacy rules.
As social media use continues to spread, the ACA Code of Ethics (2014) emphasizes
the need for counselors to develop a social media policy and to include that in their
informed consent discussions. The virtual relationship between counselor and cli-
ent and how counselors can safely maintain a virtual presence are emphasized in
ACA’s revised code (Jencius, 2015).
Becoming an Ethical Counselor
Knowing and following your profession’s code of ethics is part of being an
ethical practitioner, but these codes do not make decisions for you. As you become
involved in counseling, you will find that interpreting the ethical guidelines of your
professional organization and applying them to particular situations demand the
utmost ethical sensitivity. Even responsible practitioners differ over how to apply
established ethical principles to specific situations. In your professional work you
will deal with questions that do not always have obvious answers. You will have
to assume responsibility for deciding how to act in ways that will further the best
interests of your clients.
Throughout your professional life you will need to reexamine the ethical ques-
tions raised in this chapter. You can benefit from both formal and informal oppor-
tunities to discuss ethical dilemmas during your training program. Even if you
resolve some ethical matters while completing a graduate program, there is no guar-
antee that these matters have been settled once and for all. These topics are bound to
take on new dimensions as you gain more experience. Oftentimes students burden
themselves unnecessarily with the expectation that they should resolve all potential
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 53
ethical problem areas before they begin to practice. Throughout your professional
life, seek consultation from trusted colleagues and supervisors whenever you face an
ethical dilemma. Ethical decision making is an evolutionary process that requires
you to be continually open and self-reflective. Becoming an ethical practitioner is
not a final destination but a journey that will continue throughout your career.
Summary
It is essential that you learn a process for thinking about and dealing with ethical
dilemmas, keeping in mind that most ethical issues are complex and defy simple
solutions. A sign of good faith is your willingness to share your struggles with col-
leagues. Such consultation can be helpful in clarifying issues by giving you another
perspective on a situation. New issues are constantly surfacing, and positive eth-
ics demands periodic reflection and an openness to change on the part of the
practitioner.
If there is one fundamental question that can serve to tie together all the issues
discussed in this chapter, it is this: “Who has the right to counsel another person?”
This question can be the focal point of your reflection on ethical and professional
issues. It also can be the basis of your self-examination each day that you meet with
clients. Continue to ask yourself: “What makes me think I have a right to counsel
others?” “What do I have to offer the people I’m counseling?” “Am I doing in my own
life what I’m encouraging my clients to do?” At times you may feel that you have no
ethical right to counsel others, perhaps because your own life isn’t always the model
you would like it to be for your clients. More important than resolving all of life’s
issues is knowing what kinds of questions to ask and remaining open to reflection.
This chapter has introduced you to a number of ethical issues that you are
bound to face at some point in your counseling practice. I hope your interest has
been piqued and that you will want to learn more. For further reading on this impor-
tant topic, choose some of the books listed in the Recommended Supplementary
Readings section for further study.
Where to Go From Here
The following professional organizations provide helpful information about what
each group has to offer, including the code of ethics for the organization.
American Association for Marriage and
Family Therapy (AAMFT)
www.aamft.org
American Counseling Association (ACA) www.counseling.org
American Mental Health Counselors
Association (AMHCA)
www.amhca.org
American Music Therapy Association www.musictherapy.org
American Psychological Association
(APA)
www.apa.org
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54 C H A P T E R T H R E E
American School Counselor Association
(ASCA)
www.schoolcounselor.org
Commission on Rehabilitation Counselor
Certification (CRCC)
www.crccertification.com
National Association of Alcohol and Drug
Abuse Counselors (NAADAC)
www.naadac.org
National Association of Social Workers
(NASW)
www.socialworkers.org
National Organization for Human
Services (NOHS)
www.nationalhumanservices.org
Recommended Supplementary Readings for Part 1
The Counselor and the Law: A Guide to Legal and
Ethical Practice (Wheeler & Bertram, 2015) offers a
comprehensive overview of the law as it pertains to
counseling practice. It highlights ethical and legal
responsibilities of counselors and identifies risk-
management strategies.
Leaving It at the Office: A Guide to Psychotherapist Self-
Care (Norcross & Guy, 2007) addresses 12 self-care
strategies that are supported by empirical evidence.
The authors develop the position that self-care is
personally essential and professionally ethical. This
is one of the most useful books on therapist self-care
and on prevention of burnout.
Psychotherapy Relationships That Work: Evidence-Based
Responsiveness (Norcross, 2011) is a comprehensive
treatment of the effective elements of the therapy
relationship. Many different contributors address
ways of tailoring the therapy relationship to individ-
ual clients. Implications from research for effective
clinical practice are presented.
Ethics Desk Reference for Counselors (Barnett & John-
son, 2015) is a practical guide to understand and
applying the ACA Code of Ethics. It is a reference that
is easy to read, interesting, and has appeal for both
students and practitioners.
ACA Ethical Standards Casebook (Herlihy & Corey,
2015a) contains a variety of useful cases that are
geared to the ACA Code of Ethics. The examples
illustrate and clarify the meaning and intent of the
standards.
Boundary Issues in Counseling: Multiple Roles and
Responsibilities (Herlihy & Corey, 2015b) puts the
multiple relationship controversy into perspective.
The book focuses on dual relationships in a variety
of work settings.
Boundaries in Psychotherapy: Ethical and Clinical Explo-
rations (Zur, 2007) examines the complex nature of
boundaries in professional practice by offering a
decision-making process to help practitioners deal
with a range of topics such as gifts, nonsexual touch,
home visits, bartering, and therapist self-disclosure.
Issues and Ethics in the Helping Professions (Corey,
Corey, Corey, & Callanan, 2015) is devoted entirely
to the issues that were introduced briefly in Chap-
ter 3. Designed to involve readers in a personal and
active way, many open-ended cases are presented
to help readers formulate their own thoughts on a
wide range of ethical issues.
Becoming a Helper (M. Corey & Corey, 2016) expands
on issues dealing with the personal and professional
lives of helpers and ethical issues in counseling
practice.
Ethics in Action: DVD and Workbook (Corey, Corey, &
Haynes, 2015) is a self-instructional program divided
into three parts: (1) ethical decision making, (2) values
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E T H I C A l I s s u E s I n C o u n s E l I n g P R A C T I C E 55
and the helping relationship, and (3) boundary issues
and multiple relationships. The program includes
video clips of vignettes demonstrating ethical situa-
tions aimed at stimulating discussion.
Student Manual for Theory and Practice of Counseling
and Psychotherapy (Corey, 2017) is designed to help
you integrate theory with practice and to make the
concepts covered in this book come alive. It con-
sists of self-inventories, overview summaries of the
theories, a glossary of key concepts, study ques-
tions, issues and questions for personal applica-
tion, activities and exercises, comprehension checks
and quizzes, and case examples. The manual is fully
coordinated with the textbook to make it a personal
study guide.
The Art of Integrative Counseling (Corey, 2013a) pres-
ents concepts and techniques from the various
theories of counseling and provides guidelines for
readers in developing their own approach to coun-
seling practice.
Case Approach to Counseling and Psychotherapy (Corey,
2013b) provides case applications of how each of
the theories presented in this book works in action.
A hypothetical client, Ruth, experiences counseling
from all of the therapeutic vantage points.
DVD for Theory and Practice of Counseling and Psycho-
therapy: The Case of Stan and Lecturettes (Corey, 2013)
is an interactive self-study tool that consists of two
programs. Part 1 includes 13 sessions in which Ger-
ald Corey counsels Stan using a few selected tech-
niques from each theory. Part 2 consists of brief
lectures by the author for each chapter in Theory
and Practice of Counseling and Psychotherapy. Both pro-
grams emphasize the practical applications of the
various theories.
DVD for Integrative Counseling: The Case of Ruth and
Lecturettes (Corey & Haynes, 2013) is an interactive,
self-study tool that contains video segments and
interactive questions designed to teach students
ways of working with a client (Ruth) by drawing
concepts and techniques from diverse theoretical
approaches. The topics in this video program paral-
lel the topics in The Art of Integrative Counseling.
Creating Your Professional Path: Lessons From My Jour-
ney (Corey, 2010) is a personal book that deals with a
range of topics pertaining to the counselor as a per-
son and as a professional. In addition to the author’s
discussion of his personal and professional journey,
18 contributors share their personal stories regarding
turning points in their lives and lessons they learned.
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57
4Psychoanalytic Therapy
1. Understand the Freudian
deterministic view of human nature.
2. Identify the differences between
the id, ego, and superego.
3. Explain how ego-defense
mechanisms help individuals cope
with anxiety.
4. Understand the influence of early
childhood development on an
individual’s present problems.
5. Identify the main differences
between classical psychoanalysts
and ego psychology theorists.
6. Explain the rationale for the
analyst maintaining an anonymous
role in classical psychoanalysis.
7. Identify what is expected of clients
who participate in traditional
(classical) psychoanalysis.
8. Explain the role of transference
and countertransference in the
therapy process.
9. Define these techniques
commonly used in psychoanalytic
practice: maintaining the analytic
framework, free association,
interpretation, dream analysis,
and analysis and interpretation
of resistance and transference.
10. Understand the application of
psychodynamic concepts to group
therapy.
11. Describe unique characteristics
of the Jungian perspective on
personality development.
12. Describe these contemporary
trends in psychoanalytically
oriented therapy: object-relations
theory, self psychology, and
relational psychoanalysis.
13. Identify some of the strengths
and the shortcomings of
psychoanalysis from a
multicultural perspective.
14. Describe some of the main
contributions and limitations
of psychodynamic therapy.
L e a r n i n g O b j e c t i v e s
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58 C H A P T E R F O U R
Introduction
Freud’s views continue to influence contemporary practice. Many of his basic con-
cepts are still part of the foundation on which other theorists build and develop
their ideas. Indeed, most of the theories of counseling and psychotherapy discussed
in this book have been influenced by psychoanalytic principles and techniques.
Some of these therapeutic approaches extended the psychoanalytic model, others
modified its concepts and procedures, and others emerged as a reaction against it.
Freud’s psychoanalytic system is a model of personality development and an
approach to psychotherapy. He gave psychotherapy a new look and new horizons,
calling attention to psychodynamic factors that motivate behavior, focusing on the
role of the unconscious, and developing the first therapeutic procedures for under-
standing and modifying the structure of one’s basic character. Freud’s theory is a
benchmark against which many other theories are measured.
I begin with discussion of the basic psychoanalytic concepts and practices that
originated with Freud, then provide a glimpse of a few of the diverse approaches that
SIGMUND FREUD (1856–1939) was
the firstborn in a Viennese family of
three boys and five girls. His father, like
many others of his time and place, was
very authoritarian. Freud’s family back-
ground is a factor to consider in under-
standing the development of his theory.
Even though Freud’s family had lim-
ited finances and was forced to live in a
crowded apartment, his parents made every
effort to foster his obvious intellectual
capacities. Freud had many interests, but
his career choices were restricted because
of his Jewish heritage. He finally settled on medicine.
Only four years after earning his medical degree from
the University of Vienna at the age of 26, he attained a
prestigious position there as a lecturer.
Freud devoted most of his life to formulat-
ing and extending his theory of psychoanalysis.
Interestingly, the most creative phase of his life
corresponded to a period when he was experienc-
ing severe emotional problems of his own. During
his early 40s, Freud had numerous psychosomatic
disorders, as well as exaggerated fears of dying and
other phobias, and was involved in the difficult
task of self-analysis. By exploring the meaning of
his own dreams, he gained insights into the dynam-
ics of personality development. He first examined
his childhood memories and came to realize the
intense hostility he had felt for his
father. He also recalled his childhood
sexual feelings for his mother, who was
attractive, loving, and protective. He
then clinically formulated his theory as
he observed his patients work through
their own problems in analysis.
Freud had very little tolerance for
colleagues who diverged from his psy-
choanalytic doctrines. He attempted
to keep control over the movement by
expelling those who dared to disagree.
Carl Jung and Alfred Adler, for example,
worked closely with Freud, but each founded his own
therapeutic school after repeated disagreements with
Freud on theoretical and clinical issues.
Freud was highly creative and productive, fre-
quently putting in 18-hour days. His collected works
fill 24 volumes. Freud’s productivity remained at this
prolific level until late in his life when he contracted
cancer of the jaw. During his last two decades, he
underwent 33 operations and was in almost constant
pain. He died in London in 1939.
As the originator of psychoanalysis, Freud distin-
guished himself as an intellectual giant. He pioneered
new techniques for understanding human behav-
ior, and his efforts resulted in the most comprehen-
sive theory of personality and psychotherapy ever
developed.
Sigmund Freud
Pr
in
t C
ol
le
ct
or
/G
et
ty
Im
ag
es
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P s y C H O A n A l y T i C T H E R A P y 59
fall well within his legacy. We are in an era of theoretical pluralism in psychoana-
lytic theory today and can no longer speak of the psychoanalytic theory of treatment
(Wolitzky, 2011b). Both psychoanalysis and its more flexible variant, psychoanalyti-
cally oriented psychotherapy, are discussed in this chapter. In addition, I summarize
Erik Erikson’s theory of psychosocial development, which extends Freudian theory
in several ways, and give brief attention to Carl Jung’s approach. Finally, we look at
contemporary psychoanalytic approaches: object-relations theory, self psychology,
and the relational model of psychoanalysis. These contemporary theories are varia-
tions on psychoanalytic theory that entail modification or abandonment of Freud’s
drive theory but take Freud’s theories as their point of departure (Wolitzky, 2011b).
Although deviating significantly from traditional Freudian psychoanalysis, these
approaches retain the emphasis on unconscious processes, the role of transference
and countertransference, the existence of ego defenses and internal conflicts, and
the importance of early life experiences (McWilliams, 2016).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 4, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. i suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Key Concepts
View of Human Nature
The Freudian view of human nature is basically deterministic. According to
Freud, our behavior is determined by irrational forces, unconscious motivations,
and biological and instinctual drives as these evolve through key psychosexual
stages in the first six years of life.
Instincts are central to the Freudian approach. Although he originally used the
term libido to refer to sexual energy, he later broadened it to include the energy of all
the life instincts. These instincts serve the purpose of the survival of the individual
and the human race; they are oriented toward growth, development, and creativity.
Libido, then, should be understood as a source of motivation that encompasses sexual
energy but goes beyond it. Freud includes all pleasurable acts in his concept of the life
instincts; he sees the goal of much of life as gaining pleasure and avoiding pain.
Freud also postulates death instincts, which account for the aggressive drive.
At times, people manifest through their behavior an unconscious wish to die or to
hurt themselves or others. Managing this aggressive drive is a major challenge to the
human race. In Freud’s view, both sexual and aggressive drives are powerful determi-
nants of why people act as they do.
Structure of Personality
According to the Freudian psychoanalytic view, the personality consists of
three systems: the id, the ego, and the superego. These are names for psychological
structures and should not be thought of as manikins that separately operate the per-
sonality; one’s personality functions as a whole rather than as three discrete segments.
The id is roughly all the untamed drives or impulses that might be likened to the
biological component. The ego attempts to organize and mediate between the id and
LO1
LO2
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60 C H A P T E R F O U R
the reality of dangers posed by the id’s impulses. One way to protect ourselves from
the dangers of our own drives is to establish a superego, which is the internalized
social component, largely rooted in what the person imagines to be the expectations
of parental figures. Because the point of taking in these imagined expectations is to
protect ourselves from our own impulses, the superego may be more punitive and
demanding than the person’s parents really were. Actions of the ego may or may not
be conscious. For example, defenses typically are not conscious. Because ego and con-
sciousness are not the same, the slogan for psychoanalysis has shifted from “making
the unconscious conscious” to “where there was id, let there be ego.”
From the orthodox Freudian perspective, humans are viewed as energy systems.
The dynamics of personality consist of the ways in which psychic energy is distrib-
uted to the id, ego, and superego. Because the amount of energy is limited, one sys-
tem gains control over the available energy at the expense of the other two systems.
Behavior is determined by this psychic energy.
The ID The id is the original system of personality; at birth a person is all id. The id is
the primary source of psychic energy and the seat of the instincts. It lacks organization
and is blind, demanding, and insistent. A cauldron of seething excitement, the id
cannot tolerate tension, and it functions to discharge tension immediately. Ruled
by the pleasure principle, which is aimed at reducing tension, avoiding pain, and
gaining pleasure, the id is illogical, amoral, and driven to satisfy instinctual needs.
The id never matures, remaining the spoiled brat of personality. It does not think but
only wishes or acts. The id is largely unconscious, or out of awareness.
The Ego The ego has contact with the external world of reality. It is the “executive”
that governs, controls, and regulates the personality. As a “traffic cop,” it mediates
between the instincts and the surrounding environment. The ego controls
consciousness and exercises censorship. Ruled by the reality principle, the ego does
realistic and logical thinking and formulates plans of action for satisfying needs. The
ego, as the seat of intelligence and rationality, checks and controls the blind impulses
of the id. Whereas the id knows only subjective reality, the ego distinguishes between
mental images and things in the external world.
The Superego The superego is the judicial branch of personality. It includes a
person’s moral code, the main concern being whether an action is good or bad, right
or wrong. It represents the ideal rather than the real and strives not for pleasure but
for perfection. The superego represents the traditional values and ideals of society
as they are handed down from parents to children. It functions to inhibit the id
impulses, to persuade the ego to substitute moralistic goals for realistic ones, and to
strive for perfection. As the internalization of the standards of parents and society,
the superego is related to psychological rewards and punishments. The rewards are
feelings of pride and self-love; the punishments are feelings of guilt and inferiority.
Consciousness and the Unconscious
Perhaps Freud’s greatest contributions are his concepts of the unconscious and of
the levels of consciousness, which are the keys to understanding behavior and the
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P s y C H O A n A l y T i C T H E R A P y 61
problems of personality. The unconscious cannot be studied directly but is inferred
from behavior. Clinical evidence for postulating the unconscious includes the
following: (1) dreams, which are symbolic representations of unconscious needs,
wishes, and conflicts; (2) slips of the tongue and forgetting, for example, a famil-
iar name; (3) posthypnotic suggestions; (4) material derived from free-association
techniques; (5) material derived from projective techniques; and (6) the symbolic
content of psychotic symptoms.
For Freud, consciousness is a thin slice of the total mind. Like the greater part of
the iceberg that lies below the surface of the water, the larger part of the mind exists
below the surface of awareness. The unconscious stores all experiences, memories,
and repressed material. Needs and motivations that are inaccessible—that is, out
of awareness—are also outside the sphere of conscious control. Most psychological
functioning exists in the out-of-awareness realm. The aim of psychoanalytic therapy
is to make the unconscious motives conscious, for only then can an individual exer-
cise choice. Understanding the role of the unconscious is central to grasping the
essence of the psychoanalytic model of behavior.
Unconscious processes are at the root of all forms of neurotic symptoms and
behaviors. From this perspective, a “cure” is based on uncovering the meaning of
symptoms, the causes of behavior, and the repressed materials that interfere with
healthy functioning. It is to be noted, however, that intellectual insight alone does
not resolve the symptom. The client’s need to cling to old patterns (repetition) must
be confronted by working through transference distortions, a process discussed
later in this chapter.
Anxiety
Also essential to the psychoanalytic approach is its concept of anxiety. anxiety is a
feeling of dread that results from repressed feelings, memories, desires, and expe-
riences that emerge to the surface of awareness. It can be considered as a state of
tension that motivates us to do something. It develops out of a conflict among the
id, ego, and superego over control of the available psychic energy. The function of
anxiety is to warn of impending danger.
There are three kinds of anxiety: reality, neurotic, and moral. reality anxiety
is the fear of danger from the external world, and the level of such anxiety is pro-
portionate to the degree of real threat. Neurotic and moral anxieties are evoked by
threats to the “balance of power” within the person. They signal to the ego that
unless appropriate measures are taken the danger may increase until the ego is over-
thrown. neurotic anxiety is the fear that the instincts will get out of hand and cause
the person to do something for which she or he will be punished. Moral anxiety
is the fear of one’s own conscience. People with a well-developed conscience tend
to feel guilty when they do something contrary to their moral code. When the ego
cannot control anxiety by rational and direct methods, it relies on indirect ones—
namely, ego-defense behavior.
Ego-Defense Mechanisms
ego-defense mechanisms help the individual cope with anxiety and pre-
vent the ego from being overwhelmed. Rather than being pathological, ego defenses
LO3
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62 C H A P T E R F O U R
are normal behaviors that can have adaptive value provided they do not become
a style of life that enables the individual to avoid facing reality. The defenses
employed depend on the individual’s level of development and degree of anxiety.
Defense mechanisms have two characteristics in common: (1) they either deny or
distort reality, and (2) they operate on an unconscious level. Table 4.1 provides brief
descriptions of some common ego defenses.
TabLE 4.1 Ego-Defense Mechanisms
Defense Uses for Behavior
Repression Threatening or painful thoughts and
feelings are excluded from awareness.
One of the most important Freudian processes,
it is the basis of many other ego defenses and of
neurotic disorders. Freud explained repression as an
involuntary removal of something from consciousness.
It is assumed that most of the painful events of the
first five or six years of life are buried, yet these events
do influence later behavior.
Denial “Closing one’s eyes” to the existence of
a threatening aspect of reality.
Denial of reality is perhaps the simplest of all self-
defense mechanisms. It is a way of distorting what
the individual thinks, feels, or perceives in a traumatic
situation. This mechanism is similar to repression, yet
it generally operates at preconscious and conscious
levels.
Reaction formation Actively expressing the opposite
impulse when confronted with a
threatening impulse.
By developing conscious attitudes and behaviors
that are diametrically opposed to disturbing desires,
people do not have to face the anxiety that would
result if they were to recognize these dimensions
of themselves. Individuals may conceal hate with a
facade of love, be extremely nice when they harbor
negative reactions, or mask cruelty with excessive
kindness.
Projection Attributing to others one’s own
unacceptable desires and impulses.
This is a mechanism of self-deception. Lustful,
aggressive, or other impulses are seen as being
possessed by “those people out there, but not by me.”
Displacement Directing energy toward another object
or person when the original object or
person is inaccessible.
Displacement is a way of coping with anxiety that
involves discharging impulses by shifting from a
threatening object to a “safer target.” For example, the
meek man who feels intimidated by his boss comes
home and unloads inappropriate hostility onto his
children.
Rationalization Manufacturing “good” reasons to
explain away a bruised ego.
Rationalization helps justify specific behaviors,
and it aids in softening the blow connected with
disappointments. When people do not get positions
they have applied for in their work, they think
of logical reasons they did not succeed, and they
sometimes attempt to convince themselves that they
really did not want the position anyway.
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P s y C H O A n A l y T i C T H E R A P y 63
Sublimation Diverting sexual or aggressive energy
into other channels.
Energy is usually diverted into socially acceptable and
sometimes even admirable channels. For example,
aggressive impulses can be channeled into athletic
activities, so that the person finds a way of expressing
aggressive feelings and, as an added bonus, is often
praised.
Regression Going back to an earlier phase of
development when there were fewer
demands.
In the face of severe stress or extreme challenge,
individuals may attempt to cope with their anxiety
by clinging to immature and inappropriate behaviors.
For example, children who are frightened in school
may indulge in infantile behavior such as weeping,
excessive dependence, thumb-sucking, hiding, or
clinging to the teacher.
Introjection Taking in and “swallowing” the values
and standards of others.
Positive forms of introjection include incorporation
of parental values or the attributes and values of
the therapist (assuming that these are not merely
uncritically accepted). One negative example is that in
concentration camps some of the prisoners dealt with
overwhelming anxiety by accepting the values of the
enemy through identification with the aggressor.
Identification Identifying with successful causes,
organizations, or people in the
hope that you will be perceived as
worthwhile.
Identification can enhance self-worth and protect
one from a sense of being a failure. This is part of
the developmental process by which children learn
gender-role behaviors, but it can also be a defensive
reaction when used by people who feel basically
inferior.
Compensation Masking perceived weaknesses or
developing certain positive traits to
make up for limitations.
This mechanism can have direct adjustive value, and
it can also be an attempt by the person to say “Don’t
see the ways in which I am inferior, but see me in my
accomplishments.”
Development of Personality
Importance of Early Development A significant contribution of the
psychoanalytic model is delineation of the stages of psychosexual and psychosocial
stages of development from birth through adulthood. The psychosexual stages
refer to the Freudian chronological phases of development, beginning in infancy.
Freud postulated three early stages of development that often bring people to
counseling when not appropriately resolved. First is the oral stage, which deals with
the inability to trust oneself and others, resulting in the fear of loving and forming
close relationships and low self-esteem. Next, is the anal stage, which deals with the
inability to recognize and express anger, leading to the denial of one’s own power as
a person and the lack of a sense of autonomy. Third, is the phallic stage, which deals
with the inability to fully accept one’s sexuality and sexual feelings, and also to dif-
ficulty in accepting oneself as a man or woman. According to the Freudian psycho-
analytic view, these three areas of personal and social development—love and trust,
LO4
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64 C H A P T E R F O U R
dealing with negative feelings, and developing a positive acceptance of sexuality—are
all grounded in the first six years of life. This period is the foundation on which later
personality development is built. When a child’s needs are not adequately met dur-
ing these stages of development, an individual may become fixated at that stage and
behave in psychologically immature ways later on in life.
Erikson’s Psychosocial Perspective The developmental stages postulated
by Freud have been expanded by other theorists. Erik Erikson’s (1963) psychosocial
perspective on personality development is especially significant. Erikson built on
Freud’s ideas and extended his theory by stressing the psychosocial aspects of
development beyond early childhood. The psychosocial stages refer to Erikson’s
basic psychological and social tasks, which individuals need to master at intervals
from infancy through old age. This stage perspective provides the counselor with
the conceptual tools for understanding key developmental tasks characteristic of
the various stages of life. Erikson’s theory of development holds that psychosexual
growth and psychosocial growth take place together, and that at each stage of life
we face the task of establishing equilibrium between ourselves and our social world.
He describes development in terms of the entire life span, divided by specific crises
to be resolved. According to Erikson, a crisis is equivalent to a turning point in life
when we have the potential to move forward or to regress. At these turning points,
we can either resolve our conflicts or fail to master the developmental task. To a
large extent, our life is the result of the choices we make at each of these stages.
Erikson is often credited with bringing an emphasis on social factors to contem-
porary psychoanalysis. classical psychoanalysis is grounded on id psychology, and
it holds that instincts and intrapsychic conflicts are the basic factors shaping person-
ality development (both normal and abnormal). contemporary psychoanalysis
tends to be based on ego psychology, which does not deny the role of intrapsychic
conflicts but emphasizes the striving of the ego for mastery and competence through-
out the human life span. Ego psychology therapists assist clients in gaining awareness
of their defenses and help them develop better ways of coping with these defenses
(McWilliams, 2016). Ego psychology deals with both the early and the later develop-
mental stages, for the assumption is that current problems cannot simply be reduced
to repetitions of unconscious conflicts from early childhood. The stages of adoles-
cence, mid-adulthood, and later adulthood all involve particular crises that must be
addressed. As one’s past has meaning in terms of the future, there is continuity in
development, reflected by stages of growth; each stage is related to the other stages.
Viewing an individual’s development from a combined perspective that includes
both psychosexual and psychosocial factors is useful. Erikson believed Freud did not
go far enough in explaining the ego’s place in development and did not give enough
attention to social influences throughout the life span. A comparison of Freud’s
psychosexual view and Erikson’s psychosocial view of the stages of development is
presented in Table 4.2.
Counseling Implications By taking a combined psychosexual and psychosocial
perspective, counselors have a helpful conceptual framework for understanding
developmental issues as they appear in therapy. The key needs and developmental
tasks, along with the challenges inherent at each stage of life, provide a model for
LO5
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P s y C H O A n A l y T i C T H E R A P y 65
TabLE 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s
Psychosocial Stages
Period of Life Freud Erikson
First year of life Oral stage
Sucking at mother’s breasts satisfies need for food
and pleasure. Infant needs to get basic nurturing,
or later feelings of greediness and acquisitiveness
may develop. Oral fixations result from deprivation
of oral gratification in infancy. Later personality
problems can include mistrust of others, rejecting
others; love, and fear of or inability to form intimate
relationships.
Infancy: Trust versus mistrust
If significant others provide for basic physical
and emotional needs, infant develops a
sense of trust. If basic needs are not met,
an attitude of mistrust toward the world,
especially toward interpersonal relationships,
is the result.
Ages 1-3 Anal stage
Anal zone becomes of major significance in
formation of personality. Main developmental
tasks include learning independence, accepting
personal power, and learning to express negative
feelings such as rage and aggression. Parental
discipline patterns and attitudes have significant
consequences for child’s later personality
development.
Early childhood: Autonomy versus shame and
doubt
A time for developing autonomy. Basic
struggle is between a sense of self-reliance and
a sense of self-doubt. Child needs to explore
and experiment, to make mistakes, and to
test limits. If parents promote dependency,
child’s autonomy is inhibited and capacity to
deal with world successfully is hampered.
Ages 3-6 Phallic stage
Basic conflict centers on unconscious incestuous
desires that child develops for parent of opposite
sex and that, because of their threatening nature,
are repressed. Male phallic stage, known as Oedipus
complex, involves mother as love object for boy.
Female phallic stage, known as Electra complex,
involves girl’s striving for father’s love and approval.
How parents respond, verbally and nonverbally, to
child’s emerging sexuality has an impact on sexual
attitudes and feelings that child develops.
Preschool age: Initiative versus guilt
Basic task is to achieve a sense of competence
and initiative. If children are given freedom to
select personally meaningful activities, they
tend to develop a positive view of self and
follow through with their projects. If they are
not allowed to make their own decisions, they
tend to develop guilt over taking initiative.
They then refrain from taking an active stance
and allow others to choose for them.
Ages 6-12 Latency stage
After the torment of sexual impulses of preceding
years, this period is relatively quiescent. Sexual
interests are replaced by interests in school,
playmates, sports, and a range of new activities. This
is a time of socialization as child turns outward and
forms relationships with others.
School age: Industry versus inferiority
Child needs to expand understanding of
world, continue to develop appropriate
gender-role identity, and learn the basic skills
required for school success. Basic task is to
achieve a sense of industry, which refers to
setting and attaining personal goals. Failure to
do so results in a sense of inadequacy.
Ages 12-18 Genital stage
Old themes of phallic stage are revived. This stage
begins with puberty and lasts until senility sets
in. Even though there are societal restrictions and
taboos, adolescents can deal with sexual energy by
investing it in various socially acceptable activities
such as forming friendships, engaging in art or in
sports, and preparing for a career.
Adolescence: Identity versus role confusion A
time of transition between childhood and
adulthood.
A time for testing limits, for breaking
dependent ties, and for establishing a
new identity. Major conflicts center on
clarification of self-identity, life goals, and life’s
meaning. Failure to achieve a sense of identity
results in role confusion.
(continued)
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66 C H A P T E R F O U R
TabLE 4.2 Comparison of Freud’s Psychosexual Stages and Erikson’s
Psychosocial Stages (continued)
Period of Life Freud Erikson
Ages 18-35 Genital stage continues
Core characteristic of mature adult is the freedom
“to love and to work.” This move toward adulthood
involves freedom from parental influence and
capacity to care for others.
Young adulthood: Intimacy versus isolation.
Developmental task at this time is to form
intimate relationships. Failure to achieve
intimacy can lead to alienation and isolation.
Ages 35-60 Genital stage continues Middle age: Generativity versus stagnation.
There is a need to go beyond self and
family and be involved in helping the next
generation. This is a time of adjusting to
the discrepancy between one’s dream and
one’s actual accomplishments. Failure to
achieve a sense of productivity often leads to
psychological stagnation.
Ages 60+ Genital stage continues Later life: Integrity versus despair
If one looks back on life with few regrets and
feels personally worthwhile, ego integrity
results. Failure to achieve ego integrity can
lead to feelings of despair, hopelessness, guilt,
resentment, and self-rejection.
understanding some of the core conflicts clients explore in their therapy sessions.
Questions such as these can give direction to the therapeutic process:
�� What are some major developmental tasks at each stage in life, and how
are these tasks related to counseling?
�� What themes give continuity to this individual’s life?
�� What are some universal concerns of people at various points in life? How
can people be challenged to make life-affirming choices at these points?
�� What is the relationship between an individual’s current problems and
significant events from earlier years?
�� What choices were made at critical periods, and how did the person
deal with these various crises?
�� What are the sociocultural factors influencing development that need
to be understood if therapy is to be comprehensive?
Psychosocial theory gives special weight to childhood and adolescent factors that
are significant in later stages of development while recognizing that the later
stages also have their significant crises. Themes and threads can be found running
throughout clients’ lives.
The Therapeutic Process
Therapeutic Goals
The ultimate goal of psychoanalytic treatment is to increase adaptive function-
ing, which involves the reduction of symptoms and the resolution of conflicts
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P s y C H O A n A l y T i C T H E R A P y 67
(Wolitzky, 2011a). Two goals of Freudian psychoanalytic therapy are to make the
unconscious conscious and to strengthen the ego so that behavior is based more
on reality and less on instinctual cravings or irrational guilt. Successful analysis
is believed to result in significant modification of the individual’s personality and
character structure. Therapeutic methods are used to bring out unconscious mate-
rial. Then childhood experiences are reconstructed, discussed, interpreted, and ana-
lyzed. It is clear that the process is not limited to solving problems and learning
new behaviors. Rather, there is a deeper probing into the past to develop the level
of self-understanding that is assumed to be necessary for a change in character.
Psychoanalytic therapy is oriented toward achieving insight, but not just an intel-
lectual understanding; it is essential that the feelings and memories associated with
this self-understanding be experienced.
Therapist’s Function and Role
In classical psychoanalysis, analysts typically assume an anonymous non-
judgmental stance, which is sometimes called the “blank-screen” approach. They
avoid self-disclosure and maintain a sense of neutrality to foster a transference
relationship, in which their clients will make projections onto them. This transfer-
ence relationship is a cornerstone of psychoanalysis and “refers to the transfer of
feelings originally experienced in an early relationship to other important people in
a person’s present environment” (Luborsky, O’Reilly-Landry, & Arlow, 2011, p. 18).
If therapists say little about themselves and rarely share their personal reactions, the
assumption is that whatever the client feels toward them will largely be the product
of feelings associated with other significant figures from the past. These projections,
which have their origins in unfinished and repressed situations, are considered
“grist for the mill,” and their analysis is the very essence of therapeutic work.
One of the central functions of analysis is to help clients acquire the freedom
to love, work, and play. Other functions include assisting clients in achieving self-
awareness, honesty, and more effective personal relationships; in dealing with anxi-
ety in a realistic way; and in gaining control over impulsive and irrational behavior.
Establishing a therapeutic alliance is a primary treatment goal, and repairing any
damaged alliance is essential if therapy is to progress (McWilliams, 2014). The
empathic attunement to the client facilitates the analyst’s appreciation of the cli-
ent’s intrapsychic world (Wolitzky, 2011b). Particular attention is given to the cli-
ent’s resistances. The analyst listens in a respectful, open-minded way and decides
when to make appropriate interpretations; tact and timing are essential for effective
interpretations (McWilliams, 2014). A major function of interpretation is to acceler-
ate the process of uncovering unconscious material. The psychoanalytic therapist
pays attention to both what is spoken and what is unspoken, listens for gaps and
inconsistencies in the client’s story, infers the meaning of reported dreams and free
associations, and remains sensitive to clues concerning the client’s feelings toward
the therapist.
Organizing these therapeutic processes within the context of understanding
personality structure and psychodynamics enables the analyst to formulate the
nature of the client’s problems. One of the central functions of the analyst is to
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68 C H A P T E R F O U R
teach clients the meaning of these processes (through interpretation) so that they
are able to achieve insight into their problems, increase their awareness of ways to
change, and thus gain more control over their lives. A primary aim of psychody-
namic approaches is to foster the capacity of clients to solve their own problems.
The process of psychoanalytic therapy is somewhat like putting the pieces of a
puzzle together. Whether clients change depends considerably more on their readi-
ness to change than on the accuracy of the therapist’s interpretations. If the thera-
pist pushes the client too rapidly or offers ill-timed interpretations, therapy will not
be effective. Change occurs through the process of reworking old patterns so that
clients might become freer to act in new ways (Luborsky et al., 2011).
Client’s Experience in Therapy
Clients interested in classical psychoanalysis must be willing to commit
themselves to an intensive, long-term therapy process. After some face-to-face ses-
sions with the analyst, clients lie on a couch and engage in free association; that is,
they try to say whatever comes to mind without self-censorship. This process of free
association is known as the “fundamental rule.” Clients report their feelings, expe-
riences, associations, memories, and fantasies to the analyst. Lying on the couch
encourages deep, uncensored reflections and reduces the stimuli that might inter-
fere with getting in touch with internal conflicts and productions. It also reduces
the ability of clients to “read” their analyst’s face for reactions, which fosters the
projections characteristic of a transference.
The client in psychoanalysis experiences a unique relationship with the analyst.
The client is free to express any idea or feeling, no matter how irresponsible, scandal-
ous, politically incorrect, selfish, or infantile. The analyst remains nonjudgmental,
listening carefully and asking questions and making interpretations as the analysis
progresses. This structure encourages the client to loosen defense mechanisms and
“regress,” experiencing a less rigid level of adjustment that allows for positive thera-
peutic growth but also involves some vulnerability. It is a responsibility of the analyst
to keep the analytic situation safe for the client, so the analyst is not free to engage
in spontaneous self-expression. Every intervention by the therapist is made to fur-
ther the client’s progress. In classical analysis, therapeutic neutrality and anonymity
are valued by the analyst, and holding a consistent setting or “frame” plays a large
part in this analytic technique. Therapeutic change requires an extended period of
“working through” old patterns in the safety of the therapeutic relationship.
Psychodynamic therapy emerged as a way of shortening and simplifying the
lengthy process of classical psychoanalysis (Luborsky et al., 2011). Many psycho-
analytically oriented practitioners, or psychodynamic therapists (as distinct from
analysts), do not use all the techniques associated with classical analysis. However,
psychodynamic therapists do remain alert to transference manifestations, explore
the meaning of clients’ dreams, explore both the past and the present, offer interpre-
tations for defenses and resistance, and are concerned with unconscious material.
Traditional analytic therapists make more frequent interpretations of transferences
and engage in fewer supportive interventions than do psychodynamic therapists
(Wolitzky, 2011a).
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P s y C H O A n A l y T i C T H E R A P y 69
Clients in psychoanalytic therapy make a commitment with the therapist to
stick with the procedures of an intensive therapeutic process. They agree to talk
because their verbal productions are the heart of psychoanalytic therapy. They are
typically asked not to make any radical changes in their lifestyle during the period
of analysis, such as getting a divorce or quitting their job. The reason for avoid-
ing making such changes pertains to the therapeutic process that oftentimes is
unsettling and also associated with loosening of defenses. These restrictions are
less relevant to psychoanalytic psychotherapy than to classical psychoanalysis.
Psychoanalytic psychotherapy typically involves fewer sessions per week, the ses-
sions are usually face to face, and the therapist is supportive; hence, there is less
therapeutic “regression.”
Psychoanalytic clients are ready to terminate their sessions when they and their
analyst mutually agree that they have resolved those symptoms and core conflicts that
were amenable to resolution, have clarified and accepted their remaining emotional
problems, have understood the historical roots of their difficulties, have mastery of
core themes, have insight into how their environment affects them and how they
affect the environment, have achieved reduced defensiveness, and can integrate
their awareness of past problems with their present relationships. Wolitzky (2011a)
lists other optimal criteria for termination, including the reduction of transference,
accomplishing the main goals of therapy, an acceptance of the futility of certain
strivings and childhood fantasies, an increased capacity for love and work, achieving
more stable coping patterns, and a self-analytic capacity. Successful analysis answers
a client’s “why” questions regarding his or her life. Curtis and Hirsch (2011) suggest
that termination tends to bring up intense feelings of attachment, separation, and
loss. Thus a termination date is set well enough in advance to talk about these feel-
ings and about what the client learned in psychotherapy. Therapists assist clients in
clarifying what they have done to bring about changes.
Relationship Between Therapist and Client
There are some differences between how the therapeutic relationship is con-
ceptualized by classical analysis and contemporary relational analysis. The classical
analyst stands outside the relationship, comments on it, and offers insight-produc-
ing interpretations. In contemporary relational psychoanalysis, the therapist does
not strive for an objective stance. Contemporary psychodynamic therapists focus
as much on here-and-now transference as on earlier reenactment. By bringing the
past into the present relationship, a new understanding of the past can unfold
(Wolitzky, 2011a). Contemporary psychodynamic therapists view their emotional
communication with clients as a useful way to gain information and create connec-
tion. Analytic therapy focuses on feelings, perceptions, and action that are happen-
ing in the moment in the therapy sessions (Luborsky et al., 2011; McWilliams, 2014;
Wolitzky, 2011a, 2011b). The therapeutic relationship is central to increasing client
self-awareness, self-understanding, and exploration (Barber, Muran, McCarthy, &
Keefe, 2013). Current findings of interpersonal neurobiology lend strong support
for the effectiveness of the psychoanalytic relationship when treating clients who
have suffered interpersonal trauma and neglect (Schore, 2014).
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70 C H A P T E R F O U R
Transference and countertransference are central to understanding psychody-
namic therapy. A significant aspect of the therapeutic relationship is manifested
through transference reactions. transference is the client’s unconscious shifting to
the analyst of feelings, attitudes, and fantasies (both positive and negative) that are
reactions to significant others in the client’s past. Transference involves the uncon-
scious repetition of the past in the present. “It reflects the deep patterning of old
experiences in relationships as they emerge in current life” (Luborsky et al., 2011, p.
47). A client often has a mixture of positive and negative feelings and reactions to
a therapist. When these feelings become conscious and are transferred to the thera-
pist, clients can understand and resolve past “unfinished business.” As therapy pro-
gresses, childhood feelings and conflicts begin to surface from the depths of the
unconscious, and clients regress emotionally. Transference takes place when clients
resurrect these early intense conflicts relating to love, sexuality, hostility, anxiety,
and resentment; bring them into the present; reexperience them; and attach them to
the therapist. For example, clients may transfer unresolved feelings toward a stern
and unloving father to the therapist, who, in their eyes, becomes stern and unlov-
ing. Angry feelings are the product of negative transference, but clients also may
develop a positive transference and, for example, fall in love with the therapist, wish
to be adopted, or in many other ways seek the love, acceptance, and approval of an
all-powerful therapist. In short, the therapist becomes a current substitute for sig-
nificant others.
If therapy is to produce change, the transference relationship must be worked
through. The working-through process consists of repetitive and elaborate explo-
rations of unconscious material and defenses, most of which originated in early
childhood. Clients learn to accept their defensive structures and recognize how they
may have served a purpose in the past (Rutan, Stone, & Shay, 2014). This results in a
resolution of old patterns and enables clients to make new choices. Effective therapy
requires that the client develop a relationship with the therapist in the present that
is a corrective and integrative experience.
Clients have many opportunities to see the variety of ways in which their core
conflicts and core defenses are manifested in their daily life. It is assumed that for
clients to become psychologically independent they must not only become aware
of this unconscious material but also achieve some level of freedom from behavior
motivated by infantile strivings, such as the need for total love and acceptance from
parental figures. If this demanding phase of the therapeutic relationship is not prop-
erly worked through, clients simply transfer their infantile wishes for universal love
and acceptance to other figures. It is precisely in the client–therapist relationship
that the manifestation of these childhood motivations becomes apparent.
Regardless of the length of psychoanalytic therapy, traces of our childhood
needs and traumas will never be completely erased. Infantile conflicts may not be
fully resolved, even though many aspects of transference are worked through with
a therapist. We may need to struggle at times throughout our life with feelings that
we project onto others as well as with unrealistic demands that we expect others to
fulfill. In this sense we experience transference with many people, and our past is
always a vital part of the person we are presently becoming.
It is a mistake to assume that all feelings clients have toward their therapists are
manifestations of transference. Many of these reactions may have a reality base, and
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P s y C H O A n A l y T i C T H E R A P y 71
clients’ feelings may well be directed to the here-and-now style the therapist exhibits.
Not every positive response (such as liking the therapist) should be labeled “positive
transference.” Conversely, a client’s anger toward the therapist may be a function
of the therapist’s behavior; it is a mistake to label all negative reactions as signs of
“negative transference.”
The notion of never becoming completely free of past experiences has significant
implications for therapists who become intimately involved in the unresolved con-
flicts of their clients. Even if the conflicts of therapists have surfaced to awareness,
and even if therapists have dealt with these personal issues in their own intensive
therapy, they may still project distortions onto clients. Therapists’ countertransfer-
ence reactions are inevitable because all therapists have unresolved conflicts and
personal vulnerabilities that are activated through their professional work. From a
traditional psychoanalytic perspective, countertransference is viewed as a phenom-
enon that occurs when there is inappropriate affect, when therapists respond in irra-
tional ways, or when they lose their objectivity in a relationship because their own
conflicts are triggered. Countertransference consists of a therapist’s unconscious
emotional responses to a client based on the therapist’s own past, resulting in a dis-
torted perception of the client’s behavior (Rutan et al., 2014). Over the years this tra-
ditional view of countertransference has broadened to include all of the therapist’s
reactions, not only to the client’s transference, but to all aspects of the client’s per-
sonality and behavior. In this broader perspective, countertransference involves the
therapist’s total emotional response to a client and may include withdrawal, anger,
love, annoyance, powerlessness, avoidance, overidentification, control, or sadness.
In today’s psychoanalytic practice, countertransference is manifested in the form of
subtle nonverbal, tonal, and attitudinal actions that inevitably affect clients, either
consciously or unconsciously (Curtis & Hirsch, 2011; Wolitzky, 2011b).
To avoid misunderstanding and overidentification with clients, the analytic
approach requires therapists to undergo their own analytic psychotherapy.
McWilliams (2014) emphasizes how important it is for therapists to access and
understand their unconscious and suggests that a key outcome of therapy is humility,
which provides a good foundation for creating authentic, egalitarian, and healing
connections with clients. Personal therapy and clinical supervision for therapists
can be helpful in better understanding how internal reactions influence the therapy
process and how to use these countertransference reactions to benefit the work of
therapy (Hayes, Gelso, & Hummel, 2011).
Not all countertransference reactions are detrimental to therapeutic progress.
Indeed, countertransference reactions are often the strongest source of data for
understanding the world of the client and for self-understanding on the therapist’s
part. For example, a therapist who notes a countertransference mood of irritabil-
ity may learn something about a client’s pattern of being demanding, which can
be explored in therapy. Viewed in this more positive way, countertransference can
become a key avenue for helping the client gain self-understanding. Most research
on countertransference has dealt with its deleterious effects, but Hayes (2004) sug-
gests it would be useful to undertake systematic study of the potential therapeutic
benefits of countertransference.
Psychoanalytic therapists vary in the manner in which they use their observa-
tions of countertransference. In some instances the feelings may be shared with
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72 C H A P T E R F O U R
the client, but traditional analytic therapists strive to minimize their expression of
countertransference while silently learning from its inevitable occurrence. The abil-
ity of therapists to gain self-understanding and to establish appropriate boundaries
with clients is critical in managing and effectively using their countertransference
reactions (Hayes et al., 2011).
It is of paramount importance that therapists develop some level of objectiv-
ity and not react defensively and subjectively in the face of anger, love, adulation,
criticism, and other intense feelings expressed by their clients. If psychotherapists
become aware of a strong aversion to certain types of clients, a strong attraction
to other types of clients, psychosomatic reactions that occur at definite times in
therapeutic relationships, and the like, it is imperative for them to seek professional
consultation, clinical supervision, or enter their own therapy for a time to work out
these personal issues that stand in the way of their being effective therapists.
Through the client–therapist relationship, clients acquire insights into the
workings of their unconscious processes. Awareness of and insights into repressed
material are the bases of the analytic growth process. Clients come to understand
the association between their past experiences and their current behavior. The psy-
choanalytic approach assumes that without this dynamic self-understanding there
can be no substantial personality change or resolution of present conflicts.
Application: Therapeutic Techniques and Procedures
This section deals with the techniques most commonly used by psychoana-
lytically oriented therapists. It also includes a section on the applications of the
psychoanalytic approach to group counseling. Psychoanalytic or psychodynamic
therapy differs from traditional psychoanalysis in these ways:
�� The therapy has more to limited objectives than restructuring one’s
personality.
�� The therapist is less likely to use the couch.
�� There are fewer sessions each week.
�� There is more frequent use of supportive interventions such as reassur-
ance, expressions of empathy and support, and suggestions.
�� There is more emphasis on the here-and-now relationship between
therapist and client.
�� There is more latitude for therapist self-disclosure without “polluting
the transference.”
�� Less emphasis is given to the therapist’s neutrality.
�� There is a focus on mutual transference and countertransference
enactments.
�� The focus is more on pressing practical concerns than on working with
fantasy material.
The techniques of psychoanalytic therapy are aimed at increasing awareness,
fostering insights into the client’s behavior, and understanding the meanings of
symptoms. The therapy proceeds from the client’s talk to catharsis (or expression of
emotion), to insight, to working through unconscious material. This work is done
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P s y C H O A n A l y T i C T H E R A P y 73
to attain the goals of intellectual and emotional understanding and reeducation,
which, it is hoped, will lead to personality change. The six basic techniques of psy-
choanalytic therapy are (1) maintaining the analytic framework, (2) free association,
(3) interpretation, (4) dream analysis, (5) analysis of resistance, and (6) analysis of
transference. See Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 2)
for an illustration by Dr. William Blau, a psychoanalytically oriented therapist, of
some treatment techniques in the case of Ruth.
Maintaining the Analytic Framework
The psychoanalytic process stresses maintaining a particular framework aimed
at accomplishing the goals of this type of therapy. Maintaining the analytic
framework refers to a whole range of procedural and stylistic factors, such as the
analyst’s relative anonymity, maintaining neutrality and objectivity, the regularity
and consistency of meetings, starting and ending the sessions on time, clarity on
fees, and basic boundary issues such as the avoidance of advice giving or imposi-
tion of the therapist’s values (Curtis & Hirsch, 2011). One of the most powerful
features of psychoanalytically oriented therapy is that the consistent framework is
itself a therapeutic factor, comparable on an emotional level to the regular feeding
of an infant. Analysts attempt to minimize departures from this consistent pattern
(such as vacations, changes in fees, or changes in the meeting environment). Where
departures are unavoidable, these will often be the focus of interpretations.
Free Association
Free association is a central technique in psychoanalytic therapy, and it plays a key
role in the process of maintaining the analytic framework. In free association,
clients are encouraged to say whatever comes to mind, regardless of how painful,
silly, trivial, illogical, or irrelevant it may seem. In essence, clients try to flow with
any feelings or thoughts by reporting them immediately without censorship. As the
analytic work progresses, most clients will occasionally depart from this basic rule,
and these resistances will be interpreted by the therapist when it is timely to do so.
Free association is one of the basic tools used to open the doors to unconscious
wishes, fantasies, conflicts, and motivations. This technique often leads to some
recollection of past experiences and, at times, a catharsis or release of intense feel-
ings that have been blocked. This release is not seen as crucial in itself, however.
During the free-association process, the therapist’s task is to identify the repressed
material that is locked in the unconscious. The sequence of associations guides the
therapist in understanding the connections clients make among events. Blockings
or disruptions in associations serve as cues to anxiety-arousing material. The thera-
pist interprets the material to clients, guiding them toward increased insight into
the underlying dynamics.
As analytic therapists listen to their clients’ free associations, they hear not only
the surface content but also the hidden meaning. Nothing the client says is taken at
face value. For example, a slip of the tongue can suggest that an expressed emotion
is accompanied by a conflicting affect. Areas that clients do not talk about are as
significant as the areas they do discuss.
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74 C H A P T E R F O U R
Interpretation
interpretation consists of the analyst’s pointing out, explaining, and even teach-
ing the client the meanings of behavior that is manifested in dreams, free associa-
tion, resistances, defenses, and the therapeutic relationship itself. The functions of
interpretations are to enable the ego to assimilate new material and to speed up
the process of uncovering further unconscious material. Interpretation is grounded
in the therapist’s assessment of the client’s personality and of the factors in the
client’s past that contributed to his or her difficulties. Under contemporary defi-
nitions, interpretation includes identifying, clarifying, and translating the client’s
material. Relational psychoanalytic therapists present possible meanings associ-
ated with a client’s thoughts, feelings, or events as a hypothesis rather than a truth
about a client’s inner world (Curtis & Hirsch, 2011). Interpretations are provided in
a collaborative manner to help clients make sense of their lives and to expand their
consciousness.
The therapist uses the client’s reactions as a gauge in determining a client’s
readiness to make an interpretation. It is important that interpretations be appro-
priately timed because the client will reject therapist interpretations that are poorly
timed. A general rule is that interpretation should be presented when the phenom-
enon to be interpreted is close to conscious awareness. In other words, the therapist
should interpret material that the client has not yet seen but is capable of tolerating
and incorporating. Another general rule is that interpretation should start from the
surface and go only as deep as the client is able to go.
Dream Analysis
Dream analysis is an important procedure for uncovering unconscious material
and giving the client insight into some areas of unresolved problems. During sleep,
defenses are lowered and repressed feelings surface. Freud sees dreams as the “royal
road to the unconscious,” for in them one’s unconscious wishes, needs, and fears
are expressed. Some motivations are so unacceptable to the person that they are
expressed in disguised or symbolic form rather than being revealed directly.
Dreams have two levels of content: latent content and manifest content. Latent
content consists of hidden, symbolic, and unconscious motives, wishes, and fears.
Because they are so painful and threatening, the unconscious sexual and aggres-
sive impulses that make up latent content are transformed into the more acceptable
manifest content, which is the dream as it appears to the dreamer. The process
by which the latent content of a dream is transformed into the less threatening
manifest content is called dream work. The therapist’s task is to uncover disguised
meanings by studying the symbols in the manifest content of the dream.
During the session, therapists may ask clients to free associate to some aspect of
the manifest content of a dream for the purpose of uncovering the latent meanings.
Therapists participate in the process by exploring clients’ associations with them.
Interpreting the meanings of the dream elements helps clients unlock the repres-
sion that has kept the material from consciousness and relate the new insight to
their present struggles. Dreams may serve as a pathway to repressed material, but
dreams also provide an understanding of clients’ current functioning. Relational
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P s y C H O A n A l y T i C T H E R A P y 75
psychoanalytic therapists are particularly interested in the connection of dreams
to clients’ lives. The dream is viewed as a significant message to clients to examine
something that could be problematic if left unexamined (Curtis & Hirsch, 2011).
Analysis and Interpretation of Resistance
resistance, a concept fundamental to the practice of psychoanalysis, is anything
that works against the progress of therapy and prevents the client from producing
previously unconscious material. Specifically, resistance is the client’s reluctance
to bring to the surface of awareness unconscious material that has been repressed.
Resistance refers to any idea, attitude, feeling, or action (conscious or unconscious)
that fosters the status quo and gets in the way of change. During free association
or association to dreams, the client may evidence an unwillingness to relate cer-
tain thoughts, feelings, and experiences. Freud viewed resistance as an unconscious
dynamic that people use to defend against the intolerable anxiety and pain that
would arise if they were to become aware of their repressed impulses and feelings.
As a defense against anxiety, resistance operates specifically in psychoanalytic
therapy to prevent clients and therapists from succeeding in their joint effort to
gain insights into the dynamics of the unconscious. An assumption of analytic treat-
ment is that clients wish both to change and to remain embedded in their old world.
Clients tend to cling to their familiar patterns, regardless of how painful they may
be. Therapists need to create a safe climate so clients can recognize resistance and
explore it in therapy (Curtis & Hirsch, 2011; McWilliams, 2014; Wolitzky, 2011a).
Because resistance blocks threatening material from entering awareness, analytic
therapists point it out, but Safran and Kriss (2014) caution therapists to avoid fram-
ing resistance in a way that implies that the client is not cooperating with the treat-
ment. Therapists’ interpretations help clients become aware of the reasons for the
resistance so they can deal with them. As a general rule, therapists point out and
interpret the most obvious resistances to lessen the possibility of clients’ rejecting
the interpretation and to increase the chance that they will begin to look at their
resistive behavior.
Resistances are not just something to be overcome. Because they are representa-
tive of usual defensive approaches in daily life, they need to be recognized as devices
that defend against anxiety but that interfere with the ability to accept change that
could lead to experiencing a more gratifying life. It is crucial that therapists respect
the resistances of clients and assist them in working therapeutically with their
defenses. When handled properly, exploring resistance can be an extremely valuable
tool in understanding the client.
Analysis and Interpretation of Transference
As was mentioned earlier, transference manifests itself in the therapeutic process
when earlier relationships contribute to clients distorting the present with the ther-
apist. The transference situation is considered valuable because its manifestations
provide clients with the opportunity to reexperience a variety of feelings that would
otherwise be inaccessible. Through the relationship with the therapist, clients
express feelings, beliefs, and desires that they have buried in their unconscious.
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76 C H A P T E R F O U R
Interpreting transference is a route to elucidating the client’s intrapsychic life
(Wolitzky, 2011b). Through this interpretation, clients can recognize how they are
repeating the same dynamic patterns in their relationships with the therapist, with
significant figures from the past, and in present relationships with significant oth-
ers. Through appropriate interpretations and working through of these current
expressions of early feelings, clients are able to become aware of and to gradually
change some of their long-standing patterns of behavior. Analytically oriented ther-
apists consider the process of exploring and interpreting transference feelings as the
core of the therapeutic process because it is aimed at achieving increased awareness
and personality change.
The analysis of transference is a central technique in both classical psycho-
analysis and psychoanalytically oriented therapy, for it allows clients to achieve
here-and-now insight into the influence of the past on their present functioning.
Interpretation of the transference relationship enables clients to work through old
conflicts that are keeping them fixated and retarding their emotional growth. In
essence, the effects of early relationships are counteracted by working through a
similar emotional conflict in the current therapeutic relationship. An example of
utilizing transference is given in a later section on the case of Stan.
Application to Group Counseling
The psychodynamic model offers a conceptual framework for understand-
ing the history of the members of a group and a way of thinking about how their
past is affecting them now in the group and in their everyday lives. Group lead-
ers can think psychoanalytically, even if they do not use many psychoanalytic tech-
niques. Regardless of their theoretical orientation, it is well for group therapists to
understand such psychoanalytic phenomena as transference, countertransference,
resistance, and the use of ego-defense mechanisms as reactions to anxiety.
Transference and countertransference have significant implications for the
practice of group counseling and therapy. Group work may re-create early life situa-
tions that continue to affect the client. In most groups, individuals elicit a range of
feelings such as attraction, anger, competition, and avoidance. These transference
feelings may resemble those that members experienced toward significant people
in their past. Members will most likely find symbolic mothers, fathers, siblings, and
lovers in their group. Group participants frequently compete for the attention of the
leader—a situation reminiscent of earlier times when they had to vie for their parents’
attention with their brothers and sisters. This rivalry can be explored in a group as a
way of gaining increased awareness of how the participants dealt with competition
as children and how their past success or lack of it affects their present interactions
with others. A basic tenet of psychodynamic therapy groups is the notion that group
participants, through their interactions within the group, re-create their social situ-
ation, implying that the group becomes a microcosm of their everyday lives (Rutan
et al., 2014). Groups can provide a dynamic understanding of how people function
in out-of-group situations. Projections onto the leader and onto other members
are valuable clues to unresolved conflicts within the person that can be identified,
explored, and worked through in the group.
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P s y C H O A n A l y T i C T H E R A P y 77
The group therapist also has reactions to members and is affected by members’
reactions. Countertransference can be a useful tool for the group therapist to under-
stand the dynamics that might be operating in a group. However, group leaders need
to be alert to signs of unresolved internal conflicts that could interfere with effec-
tive group functioning and create a situation in which members are used to satisfy
the leaders’ own unfulfilled needs. If, for example, a group leader has an extreme
need to be liked and approved of, the leader might behave in ways to get members’
approval and confirmation, resulting in behaviors primarily designed to please the
group members and ensure their continued support.
Group therapists need to exercise vigilance lest they misuse their power by
turning the group into a forum for pushing clients to adjust by conforming to the
dominant cultural values at the expense of losing their own worldview and cultural
identity. Group practitioners also need to be aware of their own potential biases. The
concept of countertransference can be expanded to include unacknowledged bias
and prejudices that may be conveyed unintentionally through the techniques used
by group therapists.
For a more extensive discussion of the psychoanalytic approach to group
counseling, refer to Theory and Practice of Group Counseling (Corey, 2016, chap. 6).
Psychodynamic Group Psychotherapy (Rutan et al., 2014) also provides an excellent dis-
cussion of this subject.
Jung’s Perspective on the Development of Personality
At one time Freud referred to Carl Jung as his spiritual heir, but Jung even-
tually developed a theory of personality that was markedly different from Freudian
psychoanalysis. Jung’s analytical psychology is an elaborate explanation of human
nature that combines ideas from history, mythology, anthropology, and religion
(Schultz & Schultz, 2013). Jung made monumental contributions to our deep
understanding of the human personality and personal development, particularly
during middle age.
Jung’s pioneering work places central importance on the psychological changes
that are associated with midlife. He maintained that at midlife we need to let go of
many of the values and behaviors that guided the first half of our life and confront
our unconscious. We can best do this by paying attention to the messages of our
dreams and by engaging in creative activities such as writing or painting. The task
facing us during the midlife period is to be less influenced by rational thought and
to instead give expression to these unconscious forces and integrate them into our
conscious life (Schultz & Schultz, 2013).
Jung learned a great deal from his own midlife crisis. At age 81 he wrote about
his recollections in his autobiography, Memories, Dreams, Reflections (1961), in which
he also identified some of his major contributions. Jung made a choice to focus on
the unconscious realm in his personal life, which influenced the development of his
theory of personality. However, he had a very different conception of the uncon-
scious than did Freud. Jung was a colleague of Freud’s and valued many of his contri-
butions, but Jung eventually came to the point of not being able to support some of
Freud’s basic concepts, especially his theory of sexuality. Jung (1961) recalled Freud’s
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78 C H A P T E R F O U R
words to him: “My dear Jung, promise me never to abandon the sexual theory. This
is the most essential thing of all. You see, we must make a dogma of it, an unshak-
able bulwark” (p. 150). Jung became convinced that he could no longer collaborate
with Freud because he believed Freud placed his own authority over truth. Freud
had little tolerance for theoreticians such as Jung and Adler who dared to challenge
his theories. Although Jung had a lot to lose professionally by withdrawing from
Freud, he saw no other choice. He subsequently developed a spiritual approach that
places great emphasis on being impelled to find meaning in life in contrast to being
driven by the psychological and biological forces described by Freud.
Jung maintained that we are not merely shaped by past events (Freudian deter-
minism), but that we are influenced by our future as well as our past. Part of the
nature of humans is to be constantly developing, growing, and moving toward a bal-
anced and complete level of development. For Jung, our present personality is shaped
both by who and what we have been and also by what we aspire to be in the future.
His theory is based on the assumption that humans tend to move toward the ful-
fillment or realization of all of their capabilities. Achieving individuation—the har-
monious integration of the conscious and unconscious aspects of personality—is an
innate and primary goal. For Jung, we have both constructive and destructive forces,
and to become integrated, it is essential to accept our dark side, or shadow, with its
primitive impulses such as selfishness and greed. Acceptance of our shadow does not
imply being dominated by this dimension of our being, but simply recognizing that
this is a part of our nature.
Jung taught that many dreams contain messages from the deepest layer of the
unconscious, which he described as the source of creativity. Jung referred to the
collective unconscious as “the deepest and least accessible level of the psyche,”
which contains the accumulation of inherited experiences of human and prehu-
man species (as cited in Schultz & Schultz, 2013, p. 95). Jung saw a connection
between each person’s personality and the past, not only childhood events but
also the history of the species. This means that some dreams may deal with an
individual’s relationship to a larger whole such as the family, universal humanity,
or generations over time. The images of universal experiences contained in the col-
lective unconscious are called archetypes. Among the most important archetypes
are the persona, the anima and animus, and the shadow. The persona is a mask,
or public face, that we wear to protect ourselves. The animus and the anima rep-
resent both the biological and psychological aspects of masculinity and feminin-
ity, which are thought to coexist in both sexes. The shadow has the deepest roots
and is the most dangerous and powerful of the archetypes. It represents our dark
side, the thoughts, feelings, and actions that we tend to disown by projecting them
outward. In a dream all of these parts can be considered manifestations of who
and what we are.
Jung agreed with Freud that dreams provide a pathway into the unconscious,
but he differed from Freud on their functions. Jung wrote that dreams have two
purposes. They are prospective; that is, they help people prepare themselves for the
experiences and events they anticipate in the near future. They also serve a com-
pensatory function, working to bring about a balance between opposites within the
person. They compensate for the overdevelopment of one facet of the individual’s
personality (Schultz & Schultz, 2013).
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P s y C H O A n A l y T i C T H E R A P y 79
Jung viewed dreams more as an attempt to express than as an attempt to repress
and disguise. Dreams are a creative effort of the dreamer in struggling with contra-
diction, complexity, and confusion. The aim of the dream is resolution and integra-
tion. According to Jung, each part of the dream can be understood as some projected
quality of the dreamer. His method of interpretation draws on a series of dreams
obtained from a person, during the course of which the meaning gradually unfolds.
If you are interested in further reading, I suggest Memories, Dreams, Reflections (Jung,
1961) and Living With Paradox: An Introduction to Jungian Psychology (Harris, 1996).
Contemporary Trends: Object-Relations Theory,
Self Psychology, and Relational Psychoanalysis
Psychoanalytic theory continues to evolve. Freud emphasized intrapsychic
conflicts pertaining to the gratification of basic needs. Writers in the neo-Freudian
school moved away from this orthodox position and contributed to the growth
and expansion of the psychoanalytic movement by incorporating the cultural and
social influences on personality. ego psychology is part of classical psychoanalysis
with the emphasis placed on the vocabulary of id, ego, and superego, and on Anna
Freud’s identification of defense mechanisms. She spent most of her professional
life adapting psychoanalysis to children and adolescents. Erikson expanded this
perspective by emphasizing psychosocial development throughout the life span.
Psychoanalytic theory has evolved, undergoing a number of reformulations
over the years (McWilliams, 2016). Today psychoanalytic theory is comprised of a
variety of schools, including the classical perspective, ego psychology, object rela-
tions and interpersonal psychoanalysis, self psychology, and relational psycho-
analysis. Rutan, Stone, and Shay (2014) note some commonalities between these
psychoanalytic perspectives: “All presuppose a supportive, warm, but neutral and
fairly unobtrusive therapist who strives to create a safe, supportive, and therapeutic
relationship” (p. 73).
Object-relations theory encompasses the work of a number of rather differ-
ent psychoanalytic theorists who are especially concerned with investigating attach-
ment and separation. Their emphasize is how our relationships with other people
are affected by the way we have internalized our experiences of others and set up rep-
resentations of others within ourselves. Object relations are interpersonal relation-
ships as these are represented intrapsychically, and as they influence our interactions
with the people around us. The term object was used by Freud to refer to that which
satisfies a need, or to the significant person or thing that is the object, or target, of
one’s feelings or drives. It is used interchangeably with the term other to refer to an
important person to whom the child, and later the adult, becomes attached. Rather
than being individuals with separate identities, others are perceived by an infant
as objects for gratifying needs. Object-relations theories have diverged from ortho-
dox psychoanalysis. However, some theorists, most notably Otto Kernberg, attempt
to integrate the increasingly varied ideas that characterize this school of thought
within a classical psychoanalytic framework (St. Clair, 2004).
Traditional psychoanalysis assumes that the analyst can discover and name the
intrapersonal “truth” about individual clients. As psychoanalytic theory has evolved,
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80 C H A P T E R F O U R
the approach has more fully considered the unconscious influence of other people.
self psychology, which grew out of the work of Heinz Kohut (1971), emphasizes
how we use interpersonal relationships (self objects) to develop our own sense of self.
Kohut emphasized nonjudgmental acceptance, empathy, and authenticity. Kohut
and other self psychologists put empathy in the forefront of psychoanalytic healing
and choose interventions based on them being genuinely empathically attuned to
clients (McWilliams, 2016).
The relational model is based on the assumption that therapy is an interactive
process between client and therapist. Whether called intersubjective, interpersonal,
or relational, a number of contemporary psychoanalytic approaches are based on
the exploration of the complex conscious and unconscious dynamics at play with
respect to both therapist and client. The relational movement ushered in a new
emphasis on a more egalitarian therapeutic style (McWilliams, 2016). Relational
analysts put value on not knowing and approach clients with genuine curiosity. Ther-
apists expect to participate in mutual enactments, or repetition of themes from the
client’s life that evoke themes of their own.
From the time of Freud to the late 20th century, the power between analyst and
patient was unequal. Contemporary relational theorists have challenged what they
consider to be the authoritarian nature of the traditional psychoanalytic relation-
ship and replaced it with a more egalitarian model. The task of relational analysis is
to explore each client’s life in a creative way, customized to the therapist and client
working together in a particular culture at a particular moment in time.
Mitchell (1988, 2000) has written extensively about these new conceptualiza-
tions of the analytic relationship. He integrates developmental theory, attachment
theory, systems theory, and interpersonal theory to demonstrate the profound ways
in which we seek attachments with others, especially early caregivers. Interpersonal
analysts believe that countertransference provides an important source of informa-
tion about the client’s character and dynamics. Mitchell adds to this object-relations
position a cultural dimension, noting that the caregiver’s qualities reflect the par-
ticular culture in which the person lives. We are all deeply embedded within our
cultures. Different cultures maintain different values, so there can be no objective
psychic truths. Our internal (unconscious) structures are all relational and relative.
This is in stark contrast to the Freudian notion of universal biological drives that
could be said to function in every human.
Summary of Stages of Development
Most contemporary psychoanalytic theories center on predictable developmental
sequences in which the early experiences of the self shift in relation to an expand-
ing awareness of others. Once self–other patterns are established, it is assumed they
influence later interpersonal relationships. Specifically, people search for relation-
ships that match the patterns established by their earlier experiences. People who are
either overly dependent or overly detached, for example, can be repeating patterns
of relating they established with their mother when they were toddlers (Hedges,
1983). These newer theories provide insight into how an individual’s inner world
can cause difficulties in living in the everyday world of people and relationships
(St. Clair, 2004).
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P s y C H O A n A l y T i C T H E R A P y 81
Margaret Mahler (1968) had a central influence on contemporary object-
relations theory. A pediatrician who emphasized the observation of children, she
viewed the resolution of the Oedipus complex during Freud’s proposed phallic stage
as less critical than the child’s progression from a symbiotic relationship with a mater-
nal figure toward separation and individuation. Her studies focus on the interactions
between the child and the mother in the first thee years of life. Mahler conceptual-
izes the development of the self somewhat differently from the traditional Freudian
psychosexual stages. Her belief is that the individual begins in a state of psychologi-
cal fusion with the mother and progresses gradually to separation. The unfinished
crises and residues of the earlier state of fusion, as well as the process of separating
and individuating, have a profound influence on later relationships. Object relations
of later life build on the child’s search for a reconnection with the mother (St. Clair,
2004). Psychological development can be thought of as the evolution of the way in
which individuals separate and differentiate themselves from others.
Mahler calls the first three or four weeks of life normal infantile autism. Here the
infant is presumed to be responding more to states of physiological tension than to
psychological processes. Mahler believes the infant is unable to differentiate itself
from its mother in many respects at this age. According to Melanie Klein (1975),
another major contributor to the object-relations perspective, the infant perceives
parts—breasts, face, hands, and mouth—rather than a unified self. In this undiffer-
entiated state there is no whole self, and there are no whole objects. When adults
show the most extreme lack of psychological organization and sense of self, they
may be thought of as returning to this most primitive infantile stage. Subsequent
infant research by Daniel Stern (1985) has challenged this aspect of Mahler’s theory,
maintaining that infants are interested in others practically from birth.
Mahler’s next phase, called symbiosis, is recognizable by the 3rd month and
extends roughly through the 8th month. At this age the infant has a pronounced
dependency on the mother. She (or the primary caregiver) is clearly a partner and
not just an interchangeable part. The infant seems to expect a very high degree of
emotional attunement with its mother.
The separation–individuation process begins in the 4th or 5th month. During this
time the child moves away from symbiotic forms of relating. The child experiences
separation from significant others yet still turns to them for a sense of confirmation
and comfort. The child may demonstrate ambivalence, torn between enjoying sepa-
rate states of independence and dependence. The toddler who proudly steps away
from the parents and then runs back to be swept up in approving arms illustrates
some of the main issues of this period (Hedges, 1983, p. 109). Others are looked to as
approving mirrors for the child’s developing sense of self; optimally, these relation-
ships can provide a healthy self-esteem.
Children who do not experience the opportunity to differentiate, and those
who lack the opportunity to idealize others while also taking pride in themselves,
may later suffer from narcissistic character disorders and problems of self-esteem.
The narcissistic personality is characterized by a grandiose and exaggerated sense
of self-importance and an exploitive attitude toward others, which serve the func-
tion of masking a frail self-concept. Such individuals seek attention and admiration
from others. They unrealistically exaggerate their accomplishments, and they have a
tendency toward extreme self-absorption. Kernberg (1975) characterizes narcissistic
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82 C H A P T E R F O U R
people as focusing on themselves in their interactions with others, having a great need
to be admired, possessing shallow affect, and being exploitive and, at times, parasitic
in their relationships with others. Kohut (1971) characterizes such people as perceiv-
ing threats to their self-esteem and as having feelings of emptiness and deadness.
“Borderline” conditions are also rooted in the period of separation–individuation.
People with a borderline personality disorder have moved into the separation pro-
cess but have been thwarted by parental rejection of their individuation. In other words,
a crisis ensues when the child does develop beyond the stage of symbiosis, but the par-
ents are unable to tolerate this beginning individuation and withdraw emotional sup-
port. Borderline people are characterized by instability, irritability, self-destructive acts,
impulsive anger, and extreme mood shifts. They typically experience extended periods
of disillusionment, punctuated by occasional euphoria. Kernberg (1975) describes the
syndrome as including a lack of clear identity, a lack of deep understanding of other
people, poor impulse control, and the inability to tolerate anxiety.
Mahler’s final subphase in the separation–individuation process involves a
move toward constancy of self and object. This development is typically pronounced
by the 36th month (Hedges, 1983). By now others are more fully seen as separate
from the self. Ideally, children can begin to relate without being overwhelmed with
fears of losing their sense of individuality, and they may enter into the later psycho-
sexual and psychosocial stages with a firm foundation of selfhood. Borderline and
narcissistic disorders seem to be rooted in traumas and developmental disturbances
during the separation–individuation phase. However, the full manifestations of the
personality and behavioral symptoms tend to develop in early adulthood.
This chapter permits only a glimpse of the newer formulations in psychoana-
lytic theory. If you would like to pursue this emerging approach, good overviews can
be found in Mitchell (1988, 2000), Mitchell and Black (1995), and Wolitzky (2011b).
Treating borderline and Narcissistic Disorders Some of the most powerful
tools for understanding borderline and narcissistic personality disorders have
emerged from the psychoanalytic models. Among the most significant theorists in
this area are Kernberg (1975, 1976, 1997; Kernberg, Yeomans, Clarkin, & Levy, 2008),
Kohut (1971, 1977, 1984), and Masterson (1976). A great deal of psychoanalytic
writing deals with the nature and treatment of borderline and narcissistic
personality disorders and sheds new light on the understanding of these disorders.
Kohut (1984) maintains that people are their healthiest and best when they can
feel both independence and attachment, taking joy in themselves and also being
able to idealize others. Mature adults feel a basic security grounded in a sense of
freedom, self-sufficiency, and self-esteem; they are not compulsively dependent on
others but also do not have to fear closeness. If you are interested in learning more
about treating individuals with borderline personality disorders from an object-
relations perspective, see Psychotherapy for Borderline Personality (Clarkin, Yeomans,
& Kernberg, 2006).
Some Directions of Contemporary Psychodynamic Therapy
Strupp (1992) maintains that the various contemporary modifications of psycho-
analysis have infused psychodynamic psychotherapy with renewed vitality and
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P s y C H O A n A l y T i C T H E R A P y 83
vigor. Although long-term analytic therapy will remain a luxury for most people in
our society, Strupp sees a growing trend toward short-term treatments for specific
disorders, limited goals, and containment of costs. Some of the directions in psy-
chodynamic theory and practice that Strupp identifies are summarized here:
�� Increased attention is being given to disturbances during childhood
and adolescence.
�� The emphasis on treatment has shifted to dealing therapeutically with
chronic personality disorders, borderline conditions, and narcissistic
personality disorders. There is also a movement toward devising specific
treatments for specific disorders.
�� Increased attention is being paid to establishing a good therapeutic
alliance early in therapy. A collaborative working relationship is now
viewed as a key factor in a positive therapeutic outcome.
�� There is a renewed interest in the development of briefer forms of psy-
chodynamic therapy, largely due to societal pressures for accountability
and cost-effectiveness.
Strupp’s assessment of the current scene and his predictions for the future have
been quite accurate.
The Trend Toward brief, Time-Limited Psychodynamic Therapy Many psy-
choanalytically oriented therapists are adapting their work to a time-limited
framework while retaining their original focus on depth and the inner life. These
therapists support the use of briefer therapy when this is indicated by the client’s
needs rather than by arbitrary limits set by a managed care system. Although there
are different approaches to brief psychodynamic therapy, Prochaska and Norcross
(2014) believe they all share these common characteristics:
�� Work within the framework of time-limited therapy.
�� Target a specific interpersonal problem and goals during the initial
session.
�� Assume a less neutral therapeutic stance than is true of traditional ana-
lytic approaches.
�� Establish a strong working alliance early in the therapy.
�� Use interpretation relatively early in the therapy relationship.
Messer and Warren (2001) describe brief psychodynamic therapy (bPt) as
a promising approach. This adaptation applies the principles of psychodynamic
theory and therapy to treating selective disorders within a preestablished time limit
of, generally, 10 to 25 sessions. BPT uses key psychodynamic concepts such as the
enduring impact of psychosexual, psychosocial, and object-relational stages of
development; the existence of unconscious processes and resistance; the usefulness
of interpretation; the importance of the working alliance; and reenactment of the
client’s past emotional issues in relation to the therapist.
Most forms of the time-limited dynamic approach call upon the therapist to
assume an active and directive role in quickly formulating a therapeutic focus,
such as a central theme or problem area that guides the work (Levenson, 2010).
Some possible goals of this approach might include conflict resolution, greater
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84 C H A P T E R F O U R
access to feelings, increasing choice possibilities, improving interpersonal relation-
ships, and symptom remission. Levenson emphasizes that the aim of time-limited
dynamic therapy is not to bring about a cure but to foster changes in behavior,
thinking, and feeling. This is accomplished by using the client–therapist relation-
ship as a way to understand how the person interacts in the world. It is assumed
that clients interact with the therapist in the same dysfunctional ways they interact
with significant others.
McWilliams (2014, 2016) acknowledges the pressures psychoanalytic practitio-
ners face in creating short-term treatments that focus on unconscious processes,
especially as they are manifested and influenced in the therapeutic relationship.
Brief dynamic therapy tends to emphasize a client’s strengths, competencies, and
resources in dealing with real-life issues. Levenson (2010) notes that a major modi-
fication of the psychoanalytic technique is the emphasis on the here and now of the
client’s life rather than exploring the there and then of childhood.
BPT is an opportunity to begin the process of change, which continues long after
therapy is terminated. Short-term treatments are based on conceptual approaches
similar to those of long-term therapy, but the techniques used are different. Rather
than asking clients to free associate, practitioners ask questions, are more direct and
confrontive, and deal quickly with transference issues (Sharf, 2016). Levenson (2010)
acknowledges that the interactive, directive, focused, and self-disclosing strategies
of brief psychodynamic therapy are not suited for all clients or all therapists. This
approach is generally not suitable for individuals with severe characterological dis-
orders or for those with severe depression. BPT is more appropriate for people who
are neurotic, motivated, and focused (Sharf, 2016).
By the end of brief therapy, clients tend to have acquired a richer range of inter-
actions with others, and they continue to have opportunities to practice functional
behaviors in daily life. At some future time, clients may have a need for additional
therapy sessions to address different concerns. Instead of thinking of time-limited
dynamic psychotherapy as a definitive intervention, it is best to view this approach
as offering multiple, brief therapy experiences over an individual’s life span.
If you want to learn more about time-limited dynamic therapy, I recommend
Brief Dynamic Therapy (Levenson, 2010).
Psychoanalytic Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
Psychoanalytically oriented therapy can be made appropriate for culturally
diverse populations if techniques are modified to fit the settings in which a therapist
practices. All of us have a background of childhood experiences and have addressed
developmental crises throughout our lives. Erikson’s psychosocial approach, with
its emphasis on critical issues in stages of development, has particular application
to clients from diverse cultures. Erikson has made significant contributions to how
social and cultural factors affect people in many cultures over the life span (Sharf,
2016). Therapists can help their clients review environmental situations at the
various critical turning points in their lives to determine how certain events have
affected them either positively or negatively.
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P s y C H O A n A l y T i C T H E R A P y 85
Psychotherapists need to recognize and confront their own potential sources of
bias and how countertransference could be conveyed unintentionally through their
interventions. To the credit of the psychoanalytic approach, it stresses the value of
intensive psychotherapy as part of the training of therapists. This helps therapists
become aware of their own sources of countertransference, including their biases,
prejudices, and racial or ethnic stereotypes.
Shortcomings From a Diversity Perspective
Traditional psychoanalytic approaches are costly, and psychoanalytic therapy is gen-
erally perceived as being based on upper- and middle-class values. All clients do not
share these values, and for many the cost of treatment is prohibitive. Another short-
coming pertains to the ambiguity inherent in most psychoanalytic approaches. This
can be problematic for clients from cultures who expect direction from a profes-
sional. For example, many Asian American clients may prefer a more structured,
directive, problem-oriented approach to counseling and may not continue therapy
if a nondirective or unstructured approach is employed. Furthermore, intrapsychic
analysis may be in direct conflict with some clients’ social framework and environ-
mental perspective. Psychoanalytic therapy is generally more concerned with long-
term personality reconstruction than with short-term problems of living.
Many writers on social justice counseling emphasize how important it is to con-
sider possible external sources of clients’ problems, especially if clients have experi-
enced an oppressive environment. The psychoanalytic approach can be criticized for
failing to adequately address the social, cultural, and political factors that result in
an individual’s problems. If there is not a balance between the external and internal
perspectives, clients may feel responsible for their condition. However, the nonjudg-
mental stance that is a cornerstone of the psychoanalytic tradition may ameliorate
any tendency to blame the client.
There are likely to be some difficulties in applying a psychoanalytic approach
with low-income clients. If these clients seek professional help, they are generally
dealing with a crisis situation and want to finding solutions to concrete prob-
lems, or at least some direction in addressing survival needs pertaining to housing,
employment, and child care. This does not imply that low-income clients are unable
to profit from analytic therapy; rather, this particular orientation could be more
beneficial after more pressing issues and concerns have been resolved.
In each of the theory chapters, the case of Stan is used to demonstrate the practical applications of the the-
ory in question. Refer to the last section of Chapter 1,
where Stan’s biography is given, to refresh your mem-
ory of his central concerns.
The psychoanalytic approach focuses on the
unconscious psychodynamics of Stan’s behavior.
Considerable attention is given to material that he
has repressed. At the extreme, Stan demonstrated
a self-destructive tendency, which is a way of inflict-
ing punishment on himself. Instead of directing his
hostility toward his parents and siblings, he turned it
inward. Stan’s preoccupation with drinking could be
hypothesized as evidence of an oral fixation. Because
he never received love and acceptance during his early
childhood, he is still suffering from this deprivation
Psychoanalytic Therapy Applied to the Case of Stan
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and continues to desperately search for approval and
acceptance from others. Stan’s gender-role identifica-
tion was fraught with difficulties. He learned the basis
of female–male relationships through his early experi-
ences with his parents. What he saw was fighting, bick-
ering, and discounting. His father was the weak one
who always lost, and his mother was the strong, domi-
neering force who could and did hurt men. Stan gen-
eralized his fear of his mother to all women. It could
be further hypothesized that the woman he married
was similar to his mother, both of whom reinforced
his feelings of impotence.
The opportunity to develop a transference relation-
ship and work through it is the core of the therapy pro-
cess. Stan will eventually relate to me, as his therapist,
as he did to his father, and this process will be a valu-
able means of gaining insight into the origin of Stan’s
difficulties in relating to others. The analytic process
stresses an intensive exploration of Stan’s past. Stan
devotes much therapy time to reliving and exploring his
early past. As he talks, he gains increased understanding
of the dynamics of his behavior. He begins to see con-
nections between his present problems and early expe-
riences in his childhood. Stan explores memories of
relationships with his siblings and with his mother and
father and also explores how he has generalized his view
of women and men from his view of these family mem-
bers. It is expected that he will reexperience old feelings
and uncover buried feelings related to traumatic events.
From another perspective, apart from whatever con-
scious insight Stan may acquire, the goal is for him to
have a more integrated self, where feelings split off as
foreign (the id) become more a part of what he is com-
fortable with (the ego). In Stan’s relationship with me,
his old feelings can have different outcomes from his
past experiences with significant others and can result
in deep personality growth.
I am likely to explore some of these questions with
Stan: “What did you do when you felt unloved?” “As a
child, what did you do with your negative feelings?”
“As a child, could you express your anger, hurt, and
fears?” “What effects did your relationship with your
mother and father have on you?” “What did this teach
you about women and about men?” Brought into the
here and now of the transference relationship, I might
ask, “When have you felt anything like you felt with
your parents?”
The analytic process focuses on key influences
in Stan’s developmental years, sometimes explicitly,
sometimes in terms of how those earlier events are
being relived in the present analytic relationship. As
he comes to understand how he has been shaped by
these past experiences, Stan is increasingly able to
exert control over his present functioning. Many of
Stan’s fears become conscious, and then his energy
does not have to remain fixed on defending himself
from unconscious feelings. Instead, he can make new
decisions about his current life. He can do this only if
he works through the transference relationship, how-
ever, for the depth of his endeavors in therapy largely
determine the depth and extent of his personality
changes.
If I am operating from a contemporary object-
relations psychoanalytic orientation, my focus may
well be on Stan’s developmental sequences. Particular
attention is paid to understanding his current behav-
ior in the world as largely a repetition of one of his ear-
lier developmental phases. Because of his dependency,
it is useful in understanding his behavior to see that
he is now repeating patterns that he formed with his
mother during his infancy. Viewed from this perspec-
tive, Stan has not accomplished the task of separation
and individuation. He is still “stuck” in the symbiotic
phase on some levels. He is unable to obtain his confir-
mation of worth from himself, and he has not resolved
the dependence–independence struggle. Looking at
his behavior from the viewpoint of self psychology
can shed light on his difficulties in forming intimate
relationships.
Follow-Up: You continue
as stan’s therapist
With each of the 11 theoretical orientations, you will
be encouraged to try your hand at applying the prin-
ciples and techniques you have just studied in the
chapter to working with Stan from that particular per-
spective. The information presented about Stan from
each of these theory chapters will provide you with
some ideas of how you might continue working with
him if he were referred to you. Do your best to stay
within the general spirit of each theory by identifying
specific concepts you would draw from and techniques
that you might use in helping Stan explore the strug-
gles he identifies.
86 C H A P T E R F O U R
Psychoanalytic Therapy Applied to the Case of Gwen*
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Questions for Reflection
�� How much interest would you have in Stan’s early
childhood? What are some ways you’d help him
see patterns between his childhood issues and his
current problems?
�� Consider the transference relationship that is
likely to be established between you and Stan.
How might you react to his making you into a sig-
nificant person in his life?
�� In working with Stan, what countertransference
issues might arise for you?
�� What resistances and defenses might you predict
in your work with Stan? From a psychoanalytic
perspective, how would you interpret and work
with this resistance?
�� Which of the various forms of psychoanalytic
therapy—classical, relational, or object relations—
would you be most inclined to apply in working
with Stan?
Visit CengageBrain.com or watch the DVD for
Theory and Practice of Counseling and Psychotherapy: The
Case of Stan and Lecturettes, session 1 (an initial ses-
sion with stan) and session 2 (on psychoanalytic
therapy), for a demonstration of my approach to
counseling stan from this perspective. The first ses-
sion consists of the intake and assessment process.
The second session focuses on stan’s resistance
and dealing with transference.
P s y C H O A n A l y T i C T H E R A P y 87
In each of the theory chapters, the case of Gwen is used to demonstrate the practical applications of
that theoretical approach. Refer to the last section of
Chapter 1, where Gwen’s background information and
intake session are presented, to refresh your memory
of her central concerns.
Gwen show’s up late for her appointment and
states she is feeling frustrated with a work project she
is behind on.
Gwen: I feel like I am on the edge of falling apart, like
nothing is going right and everyone is looking at
me like I’m a failure. I am just sad and unable to
put the pieces together. I am behind on everything
… and I am scared I will lose it all.
I listen to Gwen with the goal of allowing her to con-
nect to what lies beneath the surface of her strong
emotions. As a psychoanalytic therapist, I believe the
genesis of psychological problems are rooted in the
unconscious mind. Issues brought into session often
stem from unresolved childhood conflicts and trauma.
Childhood pain and suffering is not necessarily rooted
in an extreme or horrific event; children may repress
memories of any negative emotional event.
My initial goal is to help Gwen see how her early
history is affecting her current habits, feelings, and
behaviors. Once Gwen is able to bring the unconscious
material to a conscious level, she can better under-
stand her triggers and recurrent emotional conflicts.
In making unconscious material conscious, Gwen can
recognize the origins of her behavior, explore some of
these patterns, work through early experiences, release
dysfunctional behaviors, and begin relating to life
from a position of greater clarity and strength.
Gwen continues discussing her frustrations with
work and begins to cry. I help Gwen achieve a more
relaxed state so she can bypass the conscious mind and
find out what is happening at an unconscious level.
My intervention is not the typical free association of
traditional psychoanalysis but rather guided associa-
tion based on familiar emotions.
Therapist: Sit back and relax for a moment. Go back
to one of the very first times in life when you felt
this same or a similar feeling of frustration. Let
yourself go back in time, back to when you were a
little girl and you had the sense that nothing was
going right and that things were falling apart.
[I prompt Gwen].
You feel yourself getting younger and younger. When
you are there, tell me how old you are, who is there
with you, and describe the situation.
Psychoanalytic Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a psychoanalytic perspective and applies this model to Gwen.
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I watch as Gwen’s facial expression begins to change.
After a few minutes she begins to speak.
Gwen: I am 5 years old, and I am sitting at the kitchen
table crying. I have on a pink dress, and the front
of my dress is dirty. My mother had told me to wait
for her in the car. Instead of waiting in the car, I
started playing in the backyard and got dirty. She
hit my legs, and I just cried and cried. She yelled
and told me that I always mess everything up. All I
wanted to do was to play. I never got to play, I just
wanted to kick the ball around and have some fun.
Gwen continues to cry as she tells me about her-
self as a little girl. I ask her to go to another time in
her childhood when she had that same feeling of
frustration.
Gwen: I am 12 years old, and I am upstairs in my
parent’s room. My little sister had set the bed on
fire, and my parents are blaming me because I was
supposed to be watching her. I tell them that I was
watching her. I keep telling them that it is not my
fault, but they don’t listen to me. They put me on
punishment for two months, and I overhear them
say that I never do anything right.
Therapist: What did that little girl need in those
situations?
Gwen: I needed understanding, and someone to
tell me it was going to be OK. I needed love, even
though I was not the perfect little girl.
I ask Gwen to reflect on what decision she made at that
time as a little girl. Gwen pauses and then replies.
Gwen: I decided I had to be perfect in order to be
loved.
I ask Gwen to reflect on how often this early decision
affects her life now. She sits quietly for a while and
then comments that she often feels like that little girl.
Gwen is surprised by the feelings and insights that
have surfaced.
Gwen: I had not thought about those early times in
ages. I can’t believe those situations still bother me.
I had not realized that.
In that moment Gwen recognizes the power of the
unconscious and how bringing the unconscious mate-
rial to the surface can serve as a healing force in her
life. I tell Gwen that as an adult she is now able to give
that little girl aspects of herself: love, acceptance, and
attention.
Gwen tells me that loving the little girl aspects of
her sounds a bit strange, but she is open to being gen-
tler with herself—just as she wanted her parents to be
easier on her and love her as she was.
Gwen: I never imagined that those spankings and
getting yelled at stuck with me all these years. So
now I see that everything seems to be connected,
and all that I have ever experienced is still affecting
me today. Wow! I have to go home and sit with all
of this.
As Gwen leaves my office, I tell her to pay attention to
her dreams and keep a dream journal for the next week
so we can continue to explore the unconscious mate-
rial through the symbols in her dreams. Gwen smiles
and says she had no idea therapy would be like this. I
remind her that psychoanalytically oriented therapy is
a long journey and that she is not alone.
It is important for me to be aware of transference
(Gwen’s unconscious reactions to me). My awareness
of transference can facilitate Gwen’s deepening con-
nection to her past. It is also important for me to be
aware of countertransference (my unconscious reac-
tions to Gwen). As Gwen spoke of getting spanked as
a child, I could relate to her pain and felt her sadness.
I could have told countless stories of pain inflicted
upon me during my childhood, but it is not my ses-
sion. However, I can use my countertransference in a
productive way by deepening my therapeutic relation-
ship with Gwen and showing empathy for the hurt
child that she was. I examine the feelings and sensa-
tions that came up for me in the session, and I chal-
lenge myself to seek supervision or peer consultation
when necessary to avoid engaging in behavior that is
not therapeutically beneficial.
Questions for Reflection
�� What interventions did the therapist make to help
Gwen begin to see how her early experiences have
an impact on her present behavior?
�� What therapeutic value do you see in facilitating
Gwen’s exploration of early childhood pain?
�� If you were counseling Gwen, what potential
countertransference issues might surface for you?
88 C H A P T E R F O U R
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P s y C H O A n A l y T i C T H E R A P y 89
Summary and Evaluation
Summary
Some major concepts of psychoanalytic theory include the dynamics of the
unconscious and its influence on behavior, the role of anxiety, an understanding of
transference and countertransference, and the development of personality at vari-
ous stages in the life cycle.
Erikson broadened Freud’s developmental perspective by including psychoso-
cial trends. In his model, each of the eight stages of human development is charac-
terized by a crisis, or turning point. We can either master the developmental task or
fail to resolve the core struggle (Table 4.2 compares Freud’s and Erikson’s views on
the developmental stages).
Psychoanalytic therapy consists largely of using methods to bring out uncon-
scious material that can be worked through. It focuses primarily on childhood
experiences, which are discussed, reconstructed, interpreted, and analyzed. The
assumption is that this exploration of the past, which is typically accomplished by
working through the transference relationship with the therapist, is necessary for
character change. The most important techniques typically employed in psychoana-
lytic practice are maintaining the analytic framework, free association, interpreta-
tion, dream analysis, analysis of resistance, and analysis of transference.
Unlike Freudian theory, Jungian theory is not reductionist. Jung viewed humans
positively and focused on individuation, the capacity of humans to move toward
wholeness and self-realization. To become what they are capable of becoming, indi-
viduals must explore the unconscious aspects of their personality, both the personal
unconscious and the collective unconscious. In Jungian analytical therapy, the ther-
apist assists the client in tapping his or her inner wisdom. The goal of therapy is not
merely the resolution of immediate problems but the transformation of personality.
The contemporary trends in psychoanalytic theory are reflected in these general
areas: ego psychology, object-relations interpersonal approaches, self psychology,
and relational approaches. Ego psychology does not deny the role of intrapsy-
chic conflicts but emphasizes the striving of the ego for mastery and competence
throughout the human life span. The object-relations approaches are based on the
notion that at birth there is no differentiation between others and self and that oth-
ers represent objects of need gratification for infants. Separation–individuation is
achieved over time. When this process is successful, others are perceived as both
separate and related. Self psychology focuses on the nature of the therapeutic rela-
tionship, using empathy as a main tool. The relational approaches emphasize what
evolves through the client–therapist relationship.
Contributions of the Classical Psychoanalytic Approach
I believe therapists can broaden their understanding of clients’ struggles by appre-
ciating Freud’s many significant contributions. It must be emphasized that compe-
tent use of psychoanalytic techniques requires training beyond what most therapists
are given in their training program. The psychoanalytic approach provides practi-
tioners with a conceptual framework for looking at behavior and for understanding
the origins and functions of symptoms. Applying the psychoanalytic point of view
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90 C H A P T E R F O U R
to therapy practice is particularly useful in (1) understanding resistances that take
the form of canceling appointments, fleeing from therapy prematurely, and refus-
ing to look at oneself; (2) understanding that unfinished business can be worked
through, so that clients can provide a new ending to some of the events that have
restricted them emotionally; (3) understanding the value and role of transference;
and (4) understanding how the overuse of ego defenses, both in the counseling rela-
tionship and in daily life, can keep clients from functioning effectively.
Although there is little to be gained from blaming the past for the way a person
is now or from dwelling on the past, considering the early history of a client is often
useful in understanding and working with a client’s current situation. The client can
use this awareness in making significant changes in the present and in future direc-
tions. Even though you may not agree with all of the premises of the classical psy-
choanalytic position, you can still draw on many of the psychoanalytic concepts as
a framework for understanding your clients and for helping them achieve a deeper
understanding of the roots of their conflicts.
Contributions of Contemporary Psychoanalytic Approaches
If the psychoanalytic (or psychodynamic) approach is considered in a broader context
than is true of classical psychoanalysis, it becomes a more powerful and useful model
for understanding human behavior. Although I find Freud’s psychosexual concepts
of value, adding Erikson’s emphasis on psychosocial factors gives a more complete
picture of the critical turning points at each stage of development. Integrating these
two perspectives is, in my view, most useful for understanding key themes in the
development of personality. Erikson’s developmental schema does not avoid the psy-
chosexual issues and stages postulated by Freud; rather, Erikson extends the stages of
psychosexual development throughout life. His perspective integrates psychosexual
and psychosocial concepts without diminishing the importance of either.
Therapists who work from a developmental perspective are able to see continu-
ity in life and to see certain directions their clients have taken. This perspective gives
a broader picture of an individual’s struggle, and clients are able to discover some
significant connections among the various life stages.
The contemporary trends in psychoanalytic thinking contribute to the under-
standing of how our current behavior in the world is largely a repetition of patterns set
during one of the early phases of development. Object-relations theory helps us see the
ways in which clients interacted with significant others in the past and how they are
superimposing these early experiences on present relationships. For the many clients in
therapy who are struggling with issues such as separation and individuation, intimacy,
dependence versus independence, and identity, these newer formulations can provide
a framework for understanding how and where aspects of development have been
fixated. They have significant implications for many areas of human interaction such as
intimate relationships, the family and child rearing, and the therapeutic relationship.
In my opinion, it is possible to use key concepts of a psychodynamic framework to
provide structure and direction to a counseling practice and at the same time to draw
on other therapeutic techniques. I find value in the contributions of those writers who
have built on the basic ideas of Freud and have added an emphasis on the social and cul-
tural dimensions affecting personality development. In contemporary psychoanalytic
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P s y C H O A n A l y T i C T H E R A P y 91
practice, more latitude is given to the therapist in using techniques. The newer psy-
choanalytic theorists have enhanced, extended, and refocused classical analytic tech-
niques. They are concentrating on the development of the ego, are paying attention to
the social and cultural factors that influence the differentiation of an individual from
others, and are giving new meaning to the relational dimensions of therapy.
Several meta-analyses have found that the quality of the therapeutic relation-
ship and the therapeutic alliance are critical to the outcomes of analytic therapy, and
research attests to the overall helpfulness of psychoanalytic treatments. McWilliams
(2014) admits that psychoanalytic therapies are difficult to investigate through
randomized controlled trials because they are more complex, individualized, and
unstructured than many other therapy approaches. However, the professional com-
munity needs to appreciate the value of process research, qualitative research, case
studies, and accumulated clinical wisdom. McWilliams cites some literature on
evidence-based psychodynamic therapy and adds that literature is emerging that
supports the efficacy of psychodynamic therapies. There is also extensive empirical
literature on attachment, emotion, defenses, personality, and other areas that sup-
port the theoretical models and clinical experiences of psychoanalytic therapists.
Although contemporary psychodynamic approaches diverge considerably in
many respects from the original Freudian emphasis on drives, the basic Freudian
concepts of unconscious motivation, the influence of early development, transfer-
ence, countertransference, and resistance are still central to the newer psychody-
namic approaches. These concepts are of major importance in therapy and can be
incorporated into therapeutic practices based on various theoretical approaches.
Limitations and Criticisms of Psychoanalytic Approaches
There are a number of practical limitations of psychoanalytic therapy. Considering
factors such as time, expense, and availability of trained psychoanalytic therapists,
the practical applications of many psychoanalytic techniques are limited. This is
especially true of methods such as free association on the couch, dream analysis,
and extensive analysis of the transference relationship. A factor limiting the practi-
cal application of classical psychoanalysis is that many severely disturbed clients
lack the level of ego strength needed for this treatment.
A major limitation of traditional psychoanalytic therapy is the relatively long time
commitment required to accomplish analytic goals. Contemporary psychoanalytically
oriented therapists are interested in their clients’ past, but they intertwine that under-
standing with the present and with future goals. The emergence of brief, time-limited
psychodynamic therapy is a partial response to the criticism of lengthy therapy. Psy-
chodynamic psychotherapy evolved from traditional analysis to address the need for
treatment that was not so lengthy and involved (Luborsky et al., 2011).
A potential limitation of the psychoanalytic approach is the anonymous role
assumed by some therapists. This stance can be justified on theoretical grounds, but
in therapy situations other than classical psychoanalysis this stance is unduly restric-
tive. The newer formulations of psychoanalytic practice place considerable emphasis
on the interaction between therapist and client in the here and now, and therapists
can decide when and what to disclose to clients. Yalom (2003) suggests that appro-
priate therapist self-disclosure tends to enhance therapy outcomes. Rather than
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92 C H A P T E R F O U R
adopting a blank screen, he believes it is more productive to strive to understand the
past as a way of shedding light on the dynamics of the present therapist–client rela-
tionship. This is in keeping with the spirit of the relational analytic approach, which
emphasizes the here-and-now interaction between therapist and client.
From a feminist perspective there are distinct limitations to a number of Freudian
concepts, especially the Oedipus and Electra complexes. In her review of feminist
counseling and therapy, Enns (1993) also notes that the object-relations approach
has been criticized for its emphasis on the role of the mother–child relationship in
determining later interpersonal functioning. The approach gives great responsibility
to mothers for deficiencies and distortions in development. Fathers are conspicuously
absent from the hypothesis about patterns of early development; only mothers are
blamed for inadequate parenting. Linehan’s (1993a, 1993b, 2015) dialectical behavior
therapy (DBT), addressed in some detail in Chapter 9, is an eclectic approach that
avoids mother bashing while accepting the notion that the borderline client experi-
enced a childhood environment that was “invalidating” (Linehan, 1993a, pp. 49–52).
Luborsky, O’Reilly-Landry, and Arlow (2011) note that psychoanalytic therapies
have been criticized for being irrelevant to contemporary culture and being appro-
priate only to an elite, highly educated clientele. To this criticism, they counter with
the following statement: “Psychoanalysis is a continually evolving field that has been
revised and altered by psychoanalytic theorists and clinicians ever since its origin.
This evolution began with Freud himself, who often rethought and substantially
revised his own ideas” (p. 27).
Self-Reflection and Discussion Questions
1. What are a few key concepts of the relational psychoanalytic approach
that you would be most likely integrate into your counseling practice?
2. Psychoanalytic therapists pay particular attention to early childhood
experiences and the past as crucial determinants of present behavior.
What are your thoughts about this emphasis? How does this concept
apply to your life?
3. Transference can allow clients to explore the parallels between their
past and present experience and to acquire a new understanding of
their dynamics. What value would you place on exploring transference
with a client?
4. What are some aspects of the psychoanalytic approach that you think
could be applied to brief therapy or time-limited therapy?
5. What is one topic area that has the potential to trigger countertransfer-
ence for you? How can you identify your countertransference reactions?
How can you best manage your countertransference as a therapist?
Where to Go From Here
If this chapter has provided the impetus for you to learn more about the psycho-
analytic approach or the contemporary offshoots of psychoanalysis, you might
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P s y C H O A n A l y T i C T H E R A P y 93
consider selecting a few books from the Recommended Supplementary Readings
listed at the end of the chapter.
If you are using the DVD for Integrative Counseling: The Case of Ruth and Lecturettes,
refer to Session 10 (“Transference and Countertransference”) and compare what I’ve
written here with how I deal with transference and countertransference.
DVDs from the American Psychological Association’s Systems of Psychotherapy
Video Series that address the psychoanalytic approaches discussed in this chapter
include:
McWilliams, N. (2007). Psychoanalytic Therapy
Safran, J. (2008). Relational Psychotherapy
Safran, J. (2010). Psychoanalytic Therapy Over Time
Wachtel, P. (2008). Integrative Relational Psychotherapy
Levenson, H. (2009). Brief Dynamic Therapy Over Time
Psychotherapy.net (www.Psychotherapy.net) is a comprehensive resource for
students and professionals, offering videos and interviews with renowned psycho-
analysts such as Otto Kernberg and Nancy McWilliams. New articles, interviews,
blogs, and videos are published monthly. Two from 2011 by Otto Kernberg are:
Otto Kernberg: Live Case Consultation
Psychoanalytic Psychotherapy for Personality Disorders: An Interview with Otto
Kernberg, MD
Various colleges and universities offer special workshops or short courses
through continuing education on topics such as therapeutic considerations in
working with borderline and narcissistic personalities. These workshops could give
you a new perspective on the range of applications of contemporary psychoanalytic
therapy. For further information about training programs, workshops, and gradu-
ate programs in various states, contact:
American Psychoanalytic Association
www.apsa.org
Recommended Supplementary Readings
Psychodynamic Group Psychotherapy (Rutan, Stone,
& Shay, 2014) presents a comprehensive discussion
of various facets of psychodynamic group therapy.
Among the topics addressed are the stages of group
development, the role of the group therapist, thera-
peutic factors accounting for change, working with
difficult groups and difficult group members, and
time-limited psychodynamic groups.
Brief Dynamic Therapy (Levenson, 2010) describes
a model of psychodynamic therapy that fits the
reality of time-limited therapy and outlines the steps
toward clinical work that is both focused and deep.
The book deals with how psychoanalytic concepts
and techniques can be modified to suit the needs of
many clients who cannot participate in long-term
therapy.
Psychodynamic Psychiatry in Clinical Practice (Gabbard,
2005) offers an excellent account of various psycho-
analytic perspectives on borderline and narcissistic
disorders.
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95
5Adlerian Therapy
1. Describe these key concepts of the
Adlerian approach: purposeful
and goal-oriented behavior,
inferiority and superiority,
subjective view of reality, unity
of personality, lifestyle, and
encouragement.
2. Explain the meaning of social
interest and how this is a
foundational concept of the
Adlerian approach.
3. Define the life tasks and explain
the implications for therapy
practice.
4. Describe how Adlerians view birth
order and the implications of
sibling relationships.
5. Understand the role of the family
constellation and early recollections
in a lifestyle assessment.
6. Explain how the relationship
between therapist and client
is viewed from the Adlerian
perspective.
7. Describe the four phases of the
Adlerian therapeutic process.
8. Identify what is involved in a
thorough assessment of an
individual.
9. Explain how Adlerians view the
role of interpretation in the
therapy process.
10. Describe what is involved in the
reorientation and reeducation
process.
11. Describe areas in which the
Adlerian approach can be
applied.
12. Identify the strengths and
limitations of Adlerian therapy
from a diversity perspective.
13. Understand the unique
contributions of this approach
to the development of other
counseling approaches.
14. Identify at least one criticism of
the Adlerian approach.
L e a r n i n g O b j e c t i v e s
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96 C H A P T E R F I V E
ALFRED ADLER (1870–1937) grew up in
a Vienna family of six boys and two girls.
His younger brother died at a very young
age in the bed next to Alfred. Adler’s early
childhood was not a happy time; he was
sickly and very much aware of death. At
age 4 he almost died of pneumonia, and he
heard the doctor tell his father that “Alfred
is lost.” Adler associated this time with his
decision to become a physician. Because he
was ill so much during the first few years of
his life, Adler was pampered by his mother.
He developed a trusting relationship with
his father but did not feel very close to his mother. He
was extremely jealous of his older brother, Sigmund,
which led to a strained relationship between the two
during childhood and adolescence. When we consider
Adler’s strained relationship with Sigmund Freud, we
cannot help but suspect that patterns from his early
family constellation were repeated in this relationship.
Adler’s early childhood experiences had an
impact on the formation of his theory. Adler shaped
his own life rather than leaving it to fate. Adler was
always considered bright, but he did just enough to
get by in school until one day he realized that a math
teacher did not know the answer to a question he had
posed. Adler waited until the best students had given
it a try, and then he raised his hand and stood up.
People laughed at him, but he came up with the right
answer. After that he began to apply himself, and
he rose to the top of his class. He went on to study
medicine at the University of Vienna, entering private
practice as an ophthalmologist, and then shifting to
general medicine. He eventually specialized in neu-
rology and psychiatry, and he had a keen interest in
incurable childhood diseases.
Adler experienced anti-Semitism and the hor-
rors of World War I. Those experiences, and the
sociopolitical context of the time, contributed to his
emphasis on humanism and the need for people to
work together. He was acutely aware of the impact
of context and culture on the human per-
sonality, and his theory emanated from
this awareness.
Adler had a passionate concern for
the common person and was outspo-
ken about child-rearing practices, school
reforms, and prejudices that resulted in
conflict. He spoke and wrote in simple,
nontechnical language and advocated
for children at risk, women’s rights, the
equality of the sexes, adult education,
community mental health, family coun-
seling, and brief therapy (Watts, 2012).
Adler’s (1927/1959) Understanding Human Nature was
the first major psychology book to sell hundreds of
thousands of copies in the United States. After serv-
ing in World War I as a medical officer, Adler cre-
ated 32 child guidance clinics in the Vienna public
schools and began training teachers, social workers,
physicians, and other professionals. He pioneered the
practice of teaching professionals through live dem-
onstrations with parents and children before large
audiences, now called “open-forum” family counsel-
ing. The clinics he founded grew in number and in
popularity, and he was indefatigable in lecturing and
demonstrating his work.
Although Adler had an overcrowded work sched-
ule most of his professional life, he still took some
time to sing, enjoy music, and be with friends. In the
mid-1920s he began lecturing in the United States,
and he later made frequent visits and tours. He
ignored the warning of his friends to slow down, and
on May 28, 1937, while taking a walk before a sched-
uled lecture in Aberdeen, Scotland, Adler collapsed
and died of heart failure.
If you have an interest in learning more about
Adler’s life, see Edward Hoffman’s (1996) excellent
biography, The Drive for Self. For more on Adler’s writ-
ings and their meaning in modern society, see Jon
Carlson and Michael Maniacci’s (2012) edited book,
Alfred Adler Revisited.
JON D. CARLSON (b. 1945) grew up in a Chicago
suburb and was the youngest of four children. As the
youngest child at home and at school, he struggled
with inferiority. According to Adler, youngest chil-
dren strive to belong to the adult world and over-
achieve, and Carlson fit that pattern. As a youngster
he had asthma and serious allergies that often kept
him housebound, but he eventually “out grew” the
breathing issues and compensated by becoming a com-
petitive distance runner and university coach, earning
several national awards. He has authored or edited
more than 60 books and 300 professional training
Alfred Adler
H
ul
to
n
A
rc
hi
ve
/S
tr
in
ge
r/
G
et
ty
Im
ag
es
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A d l E R I A n T H E R A P y 97
videos and has more than 60,000 hours
of clinical practice. He earned two doc-
toral degrees in counseling and clinical
psychology, as well as the prestigious Cer-
tificate of Psychotherapy from the Adler
School in Chicago. Presently, Jon Carl-
son holds the position of Distinguished
Professor of Adlerian Psychology at Adler
University in Chicago. Carlson received
lifetime contribution awards from the
APA, ACA, and NASAP and was named
a “Living Legend in Counseling” by the
ACA in 2004.
Carlson believes professional counselors and
psychotherapists should be models of mental health
and authentic in all that they do and say, whether
inside the consulting room or out. “I take pride in
having been married to Laura for five decades and
having good relationships with all five of
our children. I served for over 30 years as
a school counselor/psychologist in our
neighborhood public school. I have prac-
ticed as couples and family therapist and
have participated on the faculty of the
Evolution of Psychotherapy Conference
demonstrating psychotherapy from an
Adlerian perspective.”
Carlson doubts that even Adler
himself would be an Adlerian today.
In Carlson’s work as editor of the Jour-
nal of Individual Psychology and keynote
speaker at several Adlerian conferences, he has
encouraged professionals to go “on beyond Adler”
and integrate Adler’s ideas with the many other valu-
able approaches available in contemporary psycho-
therapy and counseling.
JAMES ROBERT BITTER (b. 1947), coau-
thor of this chapter, is one of the leading
contemporary figures in Adlerian therapy.
He grew up in Wenatchee, Washington,
the oldest of two children, both adopted.
While still in high school, Manford Son-
stegard, a student and colleague of Rudolf
Dreikurs, started a family education cen-
ter in his town. Sonstegard would later
become Bitter’s mentor, teaching him
how to be an effective counselor.
Bitter’s mother died of cancer when
he was 14 years old, and he felt he was
largely on his own in high school and college. An
underachiever in everything, after his sophomore year
in college, a friend challenged him to approach learn-
ing seriously and take charge of his life. Bitter began
to achieve in both academic work and extracurricular
activities.
Introduced to Adlerian family counseling in
the1970s by Professor Tom Edgar, Bitter and other stu-
dents at Idaho State University opened the first family
education center in Idaho. Bitter received a master’s
degree and a doctorate at Idaho State University, then
took a job at the West Virginia College of Graduate
Studies in a counseling program chaired by Man-
ford Sonstegard. Over the next 13 years, together
they taught courses, ran workshops and conferences,
wrote papers and edited a journal, and developed an
Adlerian model for group counseling
(Sonstegard & Bitter, 2004).
After a month-long training session
led by Virginia Satir in 1979, Bitter became
part of Satir’s AVANTA Network. For the
next nine years, Bitter helped lead Satir’s
training sessions. In 1987, Satir came to
California State University at Fullerton to
help Bitter initiate a new era in the counsel-
ing program there. At Fullerton Bitter met
Jerry Corey, who encouraged Bitter to con-
tribute to this book as well as to write his
own books, one of which is Theory and Prac-
tice of Family Therapy and Counseling (Bitter, 2014). This
collaboration and friendship with Corey has continued
for more than a quarter of a century. Bitter will serve
as president of the North American Society of Adlerian
Psychology (NASAP) in 2017 and 2018.
Bitter is an Adlerian integrationist, like his friend
Jon Carlson. He integrates ideas gathered from other
people, but his foundation remains in the systemic
therapeutic practice of Adlerian psychology. Bitter
believes Adler’s emphasis on the importance of com-
munity feeling and acting with social interest are what
guarantees mental health and helps people overcome
inferiority feelings and know that they have a place in
the world. Bitter brings his philosophy and practical
experience to the discussion of Adlerian theory and
practice in this chapter.
Jon D. Carlson
Jo
n
Ca
rls
on
James Robert Bitter
Ja
m
es
B
itt
er
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98 C H A P T E R F I V E
Introduction
Along with Freud and Jung, Alfred Adler was a major contributor to the initial
development of the psychodynamic approach to therapy. After a decade of collabo-
ration, Freud and Adler parted company, with Freud declaring that Adler was a her-
etic who had deserted him. Adler resigned as president of the Vienna Psychoanalytic
Society in 1911 and founded the Society for Individual Psychology in 1912. Freud
then asserted that it was not possible to support Adlerian concepts and still remain
in good standing as a psychoanalyst.
Later, a number of other psychoanalysts deviated from Freud’s orthodox posi-
tion. These Freudian revisionists—including Karen Horney, Erich Fromm, and Harry
Stack Sullivan—agreed that relational, social, and cultural factors were of great sig-
nificance in shaping personality. Even though these three therapists are typically
called neo-Freudians, it would be more appropriate, as Heinz Ansbacher (1979) has
suggested, to refer to them as neo-Adlerians because they moved away from Freud’s
biological and deterministic point of view and toward Adler’s social-psychological
and teleological (or goal-oriented) view of human nature.
Adler stresses the unity of personality, contending that people can only be
understood as integrated and complete beings. This view also espouses the purpose-
ful nature of behavior, emphasizing that where we have come from is not as impor-
tant as where we are striving to go. Adler saw people as both the creators and the
creations of their own lives; that is, people develop a unique style of living that is
both a movement toward and an expression of their selected goals. In this sense, we
create ourselves rather than merely being shaped by our childhood experiences.
After Adler’s death in 1937, Rudolf Dreikurs was the most significant figure in
bringing Adlerian psychology to the United States, especially as its principles applied
to education, parenting, individual and group therapy, and family counseling.
Dreikurs is credited with giving impetus to the idea of child guidance centers and
to training professionals to work with a wide range of clients (Terner & Pew, 1978).
Visit CengageBrain.com or watch the dVd for the video program on Chapter 5, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Key Concepts
View of Human Nature
Adler abandoned Freud’s basic theories because he believed Freud was exces-
sively narrow in his emphasis on biological and instinctual determination. Adler
believed that the individual begins to form an approach to life somewhere in the first
six years of living. He focused on the person’s past as perceived in the present and
how an individual’s interpretation of early events continued to influence that per-
son’s present behavior. According to Adler, humans are motivated primarily by social
relatedness rather than by sexual urges; behavior is purposeful and goal-directed; and
consciousness, more than unconsciousness, is the focus of therapy. Adler stressed
choice and responsibility, meaning in life, and the striving for success, completion,
and perfection. Adler and Freud created very different theories, even though both
LO1
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A d l E R I A n T H E R A P y 99
men grew up in the same city in the same era and were educated as physicians at the
same university. Their individual and distinct childhood experiences, their personal
struggles, and the populations with whom they worked were key factors in the devel-
opment of their particular views of human nature (Schultz & Schultz, 2013).
Adler’s theory starts with a consideration of inferiority feelings, which he saw as
a normal condition of all people and as a source of all human striving. Rather than
being considered a sign of weakness or abnormality, inferiority feelings can be the
wellspring of creativity. They motivate us to strive for mastery, success (superiority),
and completion. We are driven to overcome our sense of inferiority and to strive
for increasingly higher levels of development (Ansbacher & Ansbacher, 1956/1964).
Indeed, at around 6 years of age our fictional vision of ourselves as perfect or com-
plete begins to form into a life goal. The life goal unifies the personality and becomes
the source of human motivation; every striving and every effort to overcome inferi-
ority is now in line with this goal.
From the Adlerian perspective, human behavior is neither determined by hered-
ity nor environment. Instead, we have the capacity to interpret, influence, and create
events. Adler asserted that genetics and heredity are not as important as what we
choose to do with the abilities and limitations we possess. Freud viewed people as
being fixed by their early experiences, whereas Adler believed people could change
through social learning. Although Adlerians reject a deterministic stance, they do
not go to the other extreme and maintain that individuals can become whatever
they want to be. Adlerians recognize that biological and environmental conditions
limit our capacity to choose and to create.
Adlerians put the focus on reeducating individuals and reshaping society. Adler
was the forerunner of a subjective approach to psychology that focuses on internal
determinants of behavior such as values, beliefs, attitudes, goals, interests, and the
individual perception of reality. He was a pioneer of an approach that is holistic,
social, goal oriented, systemic, and humanistic. Adler was the first systemic thera-
pist: he maintained that it is essential to understand people within the systems in
which they live.
Subjective Perception of Reality
Adlerians attempt to view the world from the client’s subjective frame of reference,
an orientation described as phenomenological. Paying attention to the individual
way in which people perceive their world, referred to as “subjective reality,” includes
the individual’s perceptions, thoughts, feelings, values, beliefs, convictions, and
conclusions. Behavior is understood from the vantage point of this subjective per-
spective. From the Adlerian perspective, objective reality is less important than how
we interpret reality and the meanings we attach to what we experience.
Unity and Patterns of Human Personality
Adler chose the name individual Psychology (from the Latin, individuum, meaning
indivisible) for his theoretical approach because he wanted to avoid Freud’s reduc-
tionist divisions such as ego, id, and superego. For Adler, Individual Psychology
meant indivisible psychology. Adler emphasized the unity and indivisibility of the
person and stressed understanding the whole person in the context of his or her
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100 C H A P T E R F I V E
life—how all dimensions of a person are interconnected components, and how all of
these components are unified by the individual’s movement toward a life goal. This
holistic concept implies that we cannot be understood in parts; rather, all aspects
of ourselves must be understood in relationship to the socially embedded contexts
of family, culture, school, and work (Carlson & Johnson, 2016). We are social, cre-
ative, decision-making beings who act with purpose and cannot be fully known out-
side the contexts that have meaning in our lives (Sherman & Dinkmeyer, 1987).
The human personality becomes unified through development of a life goal. An
individual’s thoughts, feelings, beliefs, convictions, attitudes, character, and actions
are expressions of his or her uniqueness, and all reflect a plan of life that allows for
movement toward a self-selected life goal. An implication of this holistic view of person-
ality is that the client is an integral part of a social system. There is more emphasis
on interpersonal relationships than on the individual’s internal psychodynamics.
Behavior as Purposeful and Goal Oriented Individual Psychology assumes
that all human behavior has a purpose, and this purposefulness is the cornerstone
of Adler’s theory. Adler replaced deterministic explanations with teleological
(purposive, goal-oriented) ones. A basic assumption of Individual Psychology is that
we can only think, feel, and act in relation to our goal; we can be fully understood only
in light of knowing the purposes and goals toward which we are striving. Although
Adlerians are interested in the future, they do not minimize the importance of past
influences. They assume that most decisions are based on the person’s experiences,
on the present situation, and on the direction in which the person is moving—with
the latter being the most important. They look for continuity by paying attention
to themes running through a person’s life.
Adler was influenced by the philosopher Hans Vaihinger (1965), who noted that
people often live by fictions (or views of how the world should be). People form cog-
nitive assumptions (or fictions) that serve as a map of the world. Many Adlerians use
the term fictional finalism to refer to an imagined life goal that guides a person’s
behavior. It should be noted, however, that Adler ceased using this term and replaced
it with “guiding self-ideal” and “goal of perfection” to account for our striving toward
superiority or perfection. Adler’s concept of striving for perfection implies striving for
greater competence, not only for oneself but for the common good of others (Bitter,
2012; Watts, 2012). Very early in life, we begin to envision what we might be like if we
were successful, complete, whole, or perfect. Applied to human motivation, a guiding
self-ideal might be expressed in this way: “Only when I am perfect can I be secure” or
“Only when I am important can I be accepted.” The guiding self-ideal represents an
individual’s image of a goal of perfection, for which he or she strives in any given situ-
ation. Because of our subjective final goal, we have the creative power to choose what
we will accept as truth, how we will behave, and how we will interpret events.
Striving for Significance and Superiority Adler stressed that the recognition
of inferiority feelings and the consequent striving for perfection or mastery are
innate (Ansbacher & Ansbacher, 1979); they are two sides of the same coin. To
understand human behavior, it is essential to grasp the ideas of basic inferiority and
compensation. From our earliest years, we need adults to care for us, but this is not
a negative factor in life. According to Adler, the moment we experience inferiority,
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A d l E R I A n T H E R A P y 101
we are pulled by the striving for superiority. For example, when the toddler learns
to walk or grab a crayon, there is often an accompanying triumphant smile or
shout. This victory over inferiority is a step on the path of striving for superiority.
Adler maintained that the goal of success pulls people forward toward mastery and
enables them to overcome obstacles.
The goal of superiority contributes to the development of human community.
However, it is important to note that “superiority,” as used by Adler, does not neces-
sarily mean superiority over others. Rather, it means moving from a perceived lower
(or minus) position to a perceived better (or plus) position in relation to oneself.
People cope with feelings of helplessness by striving for competence, self-mastery,
and perfection. They can seek to change a weakness into a strength, for example, or
strive to excel in one area to compensate for defects in other areas. The unique ways
in which people develop a style of striving for competence is what constitutes indi-
viduality or lifestyle. The manner in which Adler reacted to his childhood and ado-
lescent experiences of loss, rejection, and poor academic grades is a living example of
this aspect of his theory.
Lifestyle The movement from a felt minus to a desired plus results in the
development of a life goal, which in turn unifies the personality and the individual’s
core beliefs and assumptions. These core beliefs and assumptions guide each
person’s movement through life and organize his or her reality, giving meaning to
life events. Adler called this life movement the individual’s “lifestyle.” Synonyms for
this term include “plan of life,” “style of life,” “strategy for living,” and “road map
of life.” Lifestyle, often described as our perceptions regarding self, others, and the
world, includes the connecting themes and rules of interaction that give meaning to
our actions. It is the characteristic way we think, act, feel, perceive, and live (Carlson
& Johnson, 2016).
Adler saw us as actors, creators, and artists. Understanding one’s lifestyle is
somewhat like understanding the style of a composer: “We can begin wherever we
choose: every expression will lead us in the same direction—toward the one motive,
the one melody, around which the personality is built” (Adler, as cited in Ansbacher
& Ansbacher, 1956/1964, p. 332).
People are viewed as adopting a proactive, rather than a reactive, approach to
their social environment. Although events in the environment influence the devel-
opment of personality, such events are not the causes of what people become; rather,
it is our interpretation of these events that shape personality. Faulty interpretations
may lead to mistaken notions in our private logic, which will significantly influence
present behavior. Once we become aware of the patterns and continuity of our life,
we are in a position to modify those faulty assumptions and make basic changes. We
can reframe childhood experiences and consciously create a new style of living.
Social Interest and Community Feeling
Social interest and community feeling (Gemeinschaftsgefühl) are probably
Adler’s most significant and distinctive concepts (Ansbacher, 1992). These terms
refer to individuals’ awareness of being part of the human community and to indi-
viduals’ attitudes in dealing with the social world.
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102 C H A P T E R F I V E
social interest is the action line of one’s community feeling, and it involves
being as concerned about others as one is about oneself. This concept involves the
capacity to cooperate and contribute to something bigger than oneself (Milliren &
Clemmer, 2006). Social interest requires that we have enough contact with the pres-
ent to make a move toward a meaningful future, that we are willing to give and to
take, and that we develop our capacity for contributing to the welfare of others and
strive for the betterment of humanity.
The socialization process associated with social interest begins in childhood
and involves helping children find a place in society and acquire a sense of belong-
ing (Kefir, 1981). While Adler considered social interest to be innate, he also believed
that it must be learned, developed, and used. Adler equated social interest with a
sense of identification and empathy with others: “to see with the eyes of another,
to hear with the ears of another, to feel with the heart of another” (as cited in Ans-
bacher & Ansbacher, 1979, p. 42; also see Clark, 2007). For Adlerians, social interest
is the central indicator of mental health. Those with social interest tend to direct
their striving toward the healthy and socially useful side of life. As social interest
develops, feelings of inferiority and alienation diminish. People express social inter-
est through shared activity, cooperation, participation in the common good, and
mutual respect (Carlson & Johnson, 2016).
Individual Psychology rests on a central belief that our happiness and success
are largely related to this social connectedness. Because we are embedded in a soci-
ety, and indeed in the whole of humanity, we cannot be understood in isolation
from that social context. We are primarily motivated by a desire to belong. commu-
nity feeling embodies the feeling of being connected to all of humanity—past, pres-
ent, and future—and to being involved in making the world a better place. Community
feeling entails the evolutionary need to belong, and it manifests itself in courage,
empathy, caring, compassion, engagement, and cooperation (Bitter, 2012). Those
who lack this community feeling become discouraged and end up on the useless side
of life. We seek a place in the family and in society to fulfill basic needs for security,
acceptance, and worthiness. Many of the problems we experience are related to the
fear of not being accepted by the groups we value. If our sense of belonging is not
fulfilled, anxiety is the result. Only when we feel united with others are we able to act
with courage in facing and dealing with our problems (Adler, 1938/1964).
The Life Tasks
Adler taught that we must successfully master three universal life tasks:
building friendships (social task), establishing intimacy (love–marriage task), and
contributing to society (occupational task). All people need to address these tasks,
regardless of age, gender, time in history, culture, or nationality. Each of these
tasks requires the development of psychological capacities for friendship and belong-
ing, for contribution and self-worth, and for cooperation (Bitter, 2007). These basic life
tasks are so fundamental that impairment in any one of them is often an indica-
tor of a psychological disorder (American Psychiatric Association, 2013). Our per-
sonality is the result of stances we have taken in relation to the life tasks we face
(Bitter, 2012). More often than not, when people seek therapy, it is because they
are struggling unsuccessfully to meet one or more of these life tasks. The aim of
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A d l E R I A n T H E R A P y 103
therapy is to encourage clients to develop increased social interest and to modify
their lifestyle so they can more effectively navigate each of these life tasks (Carlson
& Johnson, 2016).
Most people get into difficulty when they lack courage and seek to avoid the
demands posed by these life tasks. Adler (1929/1969) introduced “The Question” as
a means of determining which life task a problem or symptom might be helping the
person avoid. In its original form, the question asked was “What would you do if you
were quite well?” (p. 201). If the person answered that he would complete his examina-
tions at school if not for his anxiety, Adler knew that the anxiety was needed for the
person to avoid the possibility of failure.
Birth Order and Sibling Relationships
The Adlerian approach is unique in giving special attention to the relation-
ships between siblings and the psychological birth position in one’s family. Adler
identified five psychological positions, or vantage points, from which children tend
to view life: oldest, second of only two, middle, youngest, and only. birth order is
not a deterministic concept but does increase an individual’s probability of having a
certain set of experiences. Actual birth order is less important than the individual’s
interpretation, or the psychological position of the child’s place in the family. For
example, the second born child (out of four) might experience the family from the
psychological position of a youngest child if there is a 10-year gap before the next
youngest child is born. And the third child might have the experience of a youngest
child for her first 10 years of life. Because Adlerians view most human problems as
social in nature, they emphasize relationships within the family as our earliest and,
perhaps, our most influential social system.
Adler (1931/1958) observed that many people wonder why children in the same
family often differ so widely, and he pointed out that it is a fallacy to assume that
children of the same family are formed in the same environment. Although siblings
share aspects in common in the family constellation, the psychological situation
of each child is different from that of the others due to birth order. The following
description of the influence of birth order is based on Ansbacher and Ansbacher
(1964), Dreikurs (1953), and Adler (1931/1958).
1. The oldest child generally receives a good deal of attention, and during
the time she is the only child, she is typically somewhat spoiled as the
center of attention. She tends to be dependable and hard working and
strives to keep ahead. When a new brother or sister arrives on the scene,
however, she finds herself ousted from her favored position. She is no
longer unique or special. She may readily believe that the newcomer
(or intruder) will rob her of the love to which she is accustomed. Most
often, she reasserts her position by becoming a model child, bossing
younger children, and exhibiting a high achievement drive.
2. The second child of only two is in a different position. From the time she
is born, she shares the attention with another child. The typical second
child behaves as if she was in a race and is generally under full steam at
all times. It is as though this second child were in training to surpass
the older brother or sister. This competitive struggle between the first
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104 C H A P T E R F I V E
two children influences the later course of their lives. The younger
child develops a knack for finding out the elder child’s weak spots and
proceeds to win praise from both parents and teachers by achieving
successes where the older sibling has failed. If one is talented in a given
area, the other strives for recognition by developing other abilities. The
second-born is often opposite to the firstborn.
3. The middle child often feels squeezed out. This child may become
convinced of the unfairness of life and feel cheated. This person may
assume a “poor me” attitude and can become a problem child. How-
ever, especially in families characterized by conflict, the middle child
may become the switchboard and the peacemaker, the person who
holds things together. If there are four children in a family, the second
child will often feel like a middle child and the third will be more
easygoing, more social, and may align with the firstborn.
4. The youngest child is always the baby of the family and tends to be the
most pampered one. Because of being pampered or spoiled, he may
develop helplessness into an art form and become expert at putting
others in his service. Youngest children tend to go their own way, often
developing in ways no others in the family have attempted and may
outshine everyone.
5. The only child has a problem of her own. Although she shares some of
the characteristics of the oldest child (for example, a high achievement
drive), she may not learn to share or cooperate with other children. She
will learn to deal with adults well, as they make up her original famil-
ial world. Often, the only child is pampered by her parents and may
become dependently tied to one or both of them. She may want to have
center stage all of the time, and if her position is challenged, she will
feel it is unfair.
Birth order and the interpretation of one’s position in the family have a great
deal to do with how adults interact in the world. Individuals acquire a certain style
of relating to others in childhood and form a definite picture of themselves that
they carry into their adult interactions. In Adlerian therapy, working with family
dynamics, especially relationships among siblings, assumes a key role, but Adlerians
do not dogmatically adopt the descriptions of birth order. It is important to avoid
stereotyping individuals, but certain personality trends that began in childhood as a
result of sibling rivalry can influence individuals throughout life.
The Therapeutic Process
Therapeutic Goals
Adlerian counseling and therapy rests on a collaborative arrangement between the
client and the counselor. In general, the therapeutic process includes forming a
relationship based on mutual respect; a holistic psychological investigation or lifestyle
assessment; and disclosing mistaken goals and faulty assumptions within the person’s
style of living. This is followed by a reeducation or reorientation of the client toward
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A d l E R I A n T H E R A P y 105
the useful side of life. The main aim of therapy is to develop the client’s sense of
belonging and to assist in the adoption of behaviors and processes characterized
by community feeling and social interest. This is accomplished by increasing the
client’s self-awareness and challenging and modifying his or her fundamental prem-
ises, life goals, and basic concepts (Dreikurs, 1967, 1997).
Adlerians favor the growth model of personality, with an emphasis on
strengths and well-being, rather than a pathology-based medical model. The
emphasis is on health and prevention, not remediation. Adlerian theory is an
optimistic perspective that views people as creative, unique, capable, and respon-
sible (Watts, 2012, 2015). Rather than being stuck in some kind of pathology,
Adlerians contend that clients are often discouraged. The therapeutic process
focuses on providing information, teaching, guiding, and offering encourage-
ment to discouraged clients. Encouragement is the most powerful method avail-
able for changing a person’s beliefs, for it helps clients build self-confidence and
stimulates courage. Courage is the willingness to act even when fearful in ways that
are consistent with social interest. Fear and courage go hand in hand; without
fear, there would be no need for courage. The loss of courage, or discouragement,
results in mistaken and dysfunctional behavior. Discouraged people tend to act
only in line with their perceived self-interest, which often is associated with a lack
of social interest.
Adlerian counselors provide clients with an opportunity to view things from a
different perspective, yet it is up to the clients to decide whether to accept an alterna-
tive perspective. Adlerians work collaboratively with clients to help them reach their
self-defined goals. Adlerians educate clients in new ways of looking at themselves,
others, and life. Through the process of providing clients with a new “cognitive
map,” a fundamental understanding of the purpose of their behavior, counselors
assist them in changing their perceptions. Maniacci, Sackett-Maniacci, and Mosak
(2014) identify these goals for the educational process of therapy:
�� Fostering social interest by helping clients connect with their responsi-
bility to their community
�� Helping clients overcome feelings of discouragement and inferiority
�� Modifying clients’ lifestyle in the direction of becoming more adaptive,
flexible, and social
�� Changing faulty motivation
�� Encouraging equality and acceptance of self and others
�� Helping people to become contributing members of the world
community
Therapist’s Function and Role
Adlerian therapists realize that clients can become discouraged and function
ineffectively because of mistaken beliefs, faulty values, and useless or self-absorbed
goals. Adlerians operate on the assumption that clients will feel and behave bet-
ter once they discover and correct their basic mistakes. Therapists tend to look
for major mistakes in thinking and valuing such as mistrust, selfishness, unreal-
istic ambitions, and lack of confidence. In addition to examining basic mistakes,
Adlerian therapists often help clients identify and explore their core fears, such
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106 C H A P T E R F I V E
as being imperfect, being vulnerable, being disapproved of, or suffering from past
regrets (Carlson & Englar-Carlson, 2013).
A major task for the therapist is to make a comprehensive assessment of the
client’s functioning. Therapists often gather information about the individual’s
style of living by means of a questionnaire on the client’s family constellation,
which includes parents, siblings, and others living in the home, life tasks, and early
recollections. This is a time when the assessment of birth order might be appropri-
ate. When summarized and interpreted, this questionnaire renders the individual’s
life story to this point in time. From this information on the family constellation,
the therapist is able to get a perspective on the client’s major areas of success and
failure, how the client pursues life goals, and the critical influences that have had
a bearing on the role the client has assumed in the world. These influences include
the cultural context and the sociopolitical reality in which the client lives (Carlson
& Englar-Carlson, 2013).
The counselor also uses early recollections as an assessment procedure. early
recollections (ERs) are defined as “stories of events that a person says occurred [one
time] before he or she was 10 years of age” (Mosak & Di Pietro, 2006, p. 1). ERs are
specific incidents that clients recall, along with the feelings and thoughts that accom-
panied these childhood incidents. These recollections are quite useful in getting a
better understanding of the client (Clark, 2002). After these early recollections are
summarized and interpreted, the therapist identifies some of the major successes
and mistakes in the client’s life. The aim is to provide a point of departure for the
therapeutic venture. ERs are particularly useful as a functional assessment device
because they indicate what clients do and how they think in both adaptive and mal-
adaptive ways (Mosak & Di Pietro, 2006). The process of gathering early memories is
part of what is called a lifestyle assessment, which involves learning to understand
the goals and motivations of the client. When this process is completed, the thera-
pist and the client have targets for therapy.
Client’s Experience in Therapy
How do clients maintain their lifestyle, and why do they resist changing it? A per-
son’s style of living serves the individual by staying stable and constant. In other
words, it is predictable. It is, however, also resistant to change throughout most of
one’s life. Generally, people fail to change because they do not recognize the errors
in their thinking or the purposes of their behaviors, do not know what to do differ-
ently, and are fearful of leaving old patterns for new and unpredictable outcomes.
Thus, even though their ways of thinking and behaving are not successful, they tend
to cling to familiar patterns (Sweeney, 2009). Clients in Adlerian counseling focus
their work on desired outcomes and a resilient lifestyle that can provide a new blue-
print for their actions.
In therapy, clients explore what Adlerians call private logic, the concepts about
self, others, and life that constitutes the philosophy on which an individual’s lifestyle
is based. Private logic involves our convictions and beliefs that get in the way of social
interest and that do not facilitate useful, constructive belonging (Carlson, Watts, &
Maniacci, 2006). Clients’ problems arise because the conclusions based on their pri-
vate logic often do not conform to the requirements of social living. The heart of
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A d l E R I A n T H E R A P y 107
therapy is helping clients to discover the purposes of behaviors or symptoms and the
basic mistakes associated with their personal coping. Learning how to correct faulty
assumptions and conclusions is central to therapy.
To provide a concrete example, think of a chronically depressed middle-aged
man who begins therapy. After a lifestyle assessment is completed, these basic
mistakes are identified:
�� He has convinced himself that nobody could really care about him.
�� He rejects people before they have a chance to reject him.
�� He is harshly critical of himself, expecting perfection.
�� He has expectations that things will rarely work out well.
�� He burdens himself with guilt because he is convinced he is letting
everyone down.
Even though this man may have developed these mistaken beliefs about himself
and life when he was young, he is still clinging to them as rules for living. His expec-
tations, most of which are pessimistic, tend to be fulfilled because on some level he
is seeking to validate his beliefs. Indeed, his depression will eventually serve the pur-
pose of helping him avoid contact with others, a life task at which he expects to fail.
In therapy, this man will learn how to challenge the structure of his private logic. In
his case the syllogism goes as follows:
�� “I am basically unlovable.”
�� “The world is filled with people who are likely to be rejecting.”
�� “Therefore, I must keep to myself so I won’t be hurt.”
This person holds onto several basic mistakes, and his private logic offers a psycho-
logical focus for treatment. A central theme or convictions in this client’s life might
be: “I must control everything in my life.” “I must be perfect in everything I do.”
It is easy to see how depression might follow from this thinking, but Adlerians
also know that the depression serves as an excuse for this man’s retreat from life. It
is important for the therapist to listen for the underlying purposes of this client’s
behavior. He has isolated himself from any community feeling, so his social inter-
est is low. Adlerians see feelings as being aligned with thinking and as the fuel for
behaving. First we think, then we feel, and then we act. Because emotions and cogni-
tions serve a purpose, a good deal of therapy time is spent in discovering and under-
standing this purpose and in reorienting the client toward effective ways of being.
Because the client is not perceived by the therapist to be mentally ill or emotionally
disturbed, but as mainly discouraged, the therapist will offer the client encourage-
ment so that change is possible. Through the therapeutic process, the client will dis-
cover that he or she has resources and options to draw on in dealing with significant
life issues and life tasks.
Relationship Between Therapist and Client
Adlerians consider a good client–therapist relationship to be one between
equals that is based on cooperation, mutual trust, respect, confidence, collabora-
tion, and alignment of goals. They place special value on the counselor’s modeling
of communication and acting in good faith. From the beginning of therapy, the
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108 C H A P T E R F I V E
relationship is a collaborative one, characterized by two persons working equally
toward specific, agreed-upon goals. Adlerian therapists strive to establish and main-
tain an egalitarian therapeutic alliance and a person-to-person relationship with
their clients. Developing a strong therapeutic relationship is essential to successful
outcomes. Dinkmeyer and Sperry (2000) maintain that at the outset of therapy cli-
ents should begin to formulate a plan, or contract, detailing what they want, how
they plan to get where they are heading, what is preventing them from successfully
attaining their goals, how they can change nonproductive behavior into construc-
tive behavior, and how they can make full use of their assets in achieving their pur-
poses. This therapeutic contract sets forth the goals of the therapeutic process and
specifies the responsibilities of both therapist and client. Developing a contract is
not a requirement of Adlerian therapy, but a contract can bring a tight focus to
therapy.
Application: Therapeutic Techniques and Procedures
Adlerian counseling is structured around four central objectives that corre-
spond to the four phases of the therapeutic process (Dreikurs, 1967).
1. Establish the proper therapeutic relationship.
2. Explore the psychological dynamics operating in the client (an
assessment).
3. Encourage the development of self-understanding (insight into
purpose).
4. Help the client make new choices (reorientation and reeducation).
These phases are not linear and do not progress in rigid steps; rather, they can best
be understood as a weaving that leads to a tapestry. Dreikurs (1997) incorporated
these phases into what he called minor psychotherapy in the context and service of
holistic medicine. His approach to therapy has been elaborated in what is now
called adlerian brief therapy, or ABT (Bitter, Christensen, Hawes, & Nicoll, 1998).
This way of working is discussed in the following sections.
Phase 1: Establish the Relationship
The Adlerian practitioner works in a collaborative way with clients, and this rela-
tionship is based on a sense of interest that grows into caring, involvement, and
friendship. Therapeutic progress is possible only when there is an alignment of
clearly defined goals between therapist and client. The counseling process, to be
effective, must deal with the personal issues the client recognizes as significant
and is willing to explore and change. The therapeutic efficacy in the later phases of
Adlerian therapy is predicated upon the development and continuation of a solid
therapeutic relationship during this first phase of therapy (Watts, 2015).
Adlerian therapists focus on making person-to-person contact with clients rather
than starting with “the problem.” Clients’ concerns surface rather quickly in therapy,
but the initial focus should be on the person, not the problem. One way to create
effective contact is for counselors to help clients become aware of their assets and
strengths rather than dealing continually with their deficits and liabilities. During
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A d l E R I A n T H E R A P y 109
the initial phase, a positive relationship is created by listening, responding, demon-
strating respect for clients’ capacity to understand purpose and seek change, and
exhibiting hope and caring. When clients enter therapy, they typically have a dimin-
ished sense of self-worth and self-respect. They lack faith in their ability to cope with
the tasks of life, and they often feel discouraged. Therapists provide support, which
is an antidote to despair and discouragement. For some people, therapy may be one
of the few times in which they have truly experienced a caring human relationship.
Adlerians pay more attention to the subjective experiences of the client than
they do to using techniques. During the initial phase of counseling, the therapist
works to understand the client’s identity and experience of the world. Techniques
are fitted to the needs of each client and may include attending and listening with
empathy, following the subjective experience of the client as closely as possible, iden-
tifying and clarifying goals, and suggesting initial hunches about purpose in client’s
symptoms, actions, and interactions. Adlerian counselors are generally active, espe-
cially during the initial sessions. They provide structure and assist clients in defining
personal goals, conduct psychological assessments, and offer interpretations
(Carlson et al., 2006). Adlerians attempt to grasp both the verbal and nonverbal
messages of the client; they want to access the core patterns in the client’s life. If the
client feels deeply understood and accepted, the client is likely to focus on what he
or she wants from therapy and thus establish goals. At this stage the counselor’s
function is to provide a wide-angle perspective that will eventually help the client
view his or her world differently.
Phase 2: Assessing the Individual’s Psychological Dynamics
The aim of the second phase of Adlerian counseling is to get a deeper under-
standing of an individual’s lifestyle. During this assessment phase, the focus is on
understanding the client’s identity and how that identity relates to the world at
large. This assessment phase proceeds from two interview forms: the subjective inter-
view and the objective interview (Dreikurs, 1997). In the subjective interview, the
counselor helps the client tell his or her life story as completely as possible. This
process is facilitated by a generous use of empathic listening and responding. Active
listening, however, is not enough. The subjective interview must follow from a sense
of wonder, fascination, and interest. What the client says will spark an interest in the
counselor and lead, naturally, to the next most significant question or inquiry about
the client and his or her life story. Indeed, the best subjective interviews treat clients
as experts in their own lives, allowing clients to feel completely heard. Throughout
the subjective interview, the Adlerian counselor is listening for clues to the purpo-
sive aspects of the client’s coping and approaches to life. “The subjective interview
should extract patterns in the person’s life, develop hypotheses about what works
for the person, and determine what accounts for the various concerns in the client’s
life” (Bitter et al., 1998, p. 98). Toward the end of this part of the interview, Adlerian
brief therapists ask, “Is there anything else you think I should know to understand
you and your concerns?”
An initial assessment of the purpose that symptoms, actions, or difficulties
serve in a person’s life can be gained from Dreikurs (1997) revision of “The Ques-
tion.” Adlerians often end a subjective interview by asking, “How would your life be
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110 C H A P T E R F I V E
different, and what would you be doing differently, if you did not have this symp-
tom or problem?” Adlerians use this question to help with differential diagnosis.
More often, the symptoms or problems experienced by the client help the client
avoid something that is perceived as necessary but from which the person wishes to
retreat, usually a life task: “If it weren’t for my depression, I would get out more and
see my friends.” Such a statement betrays the client’s concern about the possibility
of being a good friend or being welcomed by his or her friends. “I need to get mar-
ried, but how can I with these panic attacks?” indicates the person’s worry about
being a partner in a marriage. Depression can serve as the client’s solution when
faced with problems in relationships. If a client reports that nothing would be dif-
ferent, especially with physical symptoms, Adlerians suspect that the problem may
be organic and require medical intervention.
The objective interview seeks to discover information about (a) how problems
in the client’s life began; (b) any precipitating events; (c) a medical history, including
current and past medications; (d) a social history; (e) the reasons the client chose
therapy at this time; (f) the person’s coping with life tasks; and (g) a lifestyle assess-
ment. Based on interview approaches developed by Adler and Dreikurs, the lifestyle
assessment starts with an investigation of the person’s family constellation and early
childhood history (Powers & Griffith, 2012a; Shulman & Mosak, 1988). Counselors
also interpret the person’s early memories, seeking to understand the meaning that
she or he has attached to life experiences. They operate on the assumption that it
is the interpretations people develop about themselves, others, the world, and life
that govern what they do. Lifestyle assessment seeks to develop a holistic narrative
of the person’s life, to make sense of the way the person copes with life tasks, and to
uncover the private interpretations and logic involved in that coping. For example,
if Jenny has lived most of her life in a critical environment, and now she believes she
must be perfect to avoid even the appearance of failure, the assessment process will
highlight the restricted living that flows from this perspective. Another example is
Ramon who grew up as a child of undocumented immigrants. He lived most of his
life in fear of his environment, and he tried to remain invisible and was wary of trust-
ing others. Now he struggles to connect with peers and to maintain a committed
relationship. The assessment process explores how his lifestyle is inconsistent with
his stated goals of wanting connection.
The Family Constellation Adler considered the family of origin as having a
central impact on an individual’s personality. Adler suggested that it was through
the family constellation that each person forms his or her unique view of self, others,
and life. Factors such as cultural and familial values, gender-role expectations, and
the nature of interpersonal relationships are all influenced by a child’s observation
of the interactional patterns within the family. Adlerian assessment relies heavily on
an exploration of the client’s family constellation, including the client’s evaluation
of conditions that prevailed in the family when the person was a young child (family
atmosphere), birth order, parental relationship and family values, and extended
family and culture. Some of these questions are almost always explored:
�� Who was the favorite child?
�� What was your father’s relationship with the children? Your mother’s?
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A d l E R I A n T H E R A P y 111
�� Which child was most like your father? Your mother? In what respects?
�� Who among the siblings was most different from you? In what ways?
�� Who among the siblings was most like you? In what ways?
�� What were you like as a child?
�� How did your parents get along? In what did they both agree? How did
they handle disagreements? How did they discipline the children?
An investigation of family constellation is far more comprehensive than these few
questions, but these questions give an idea of the type of information the counselor
is seeking. The questions are always tailored to the individual client with the goal
of eliciting the client’s perceptions of self and others, of development, and of the
experiences that have affected that development.
Early Recollections As you will recall from the section on the therapist’s
functions and role, another assessment procedure used by Adlerians is to ask the
client to provide his or her earliest memories, including the age of the person at
the time of the remembered events and the feelings or reactions associated with
the recollections. Early recollections are one-time occurrences, usually before the
age of 10, that can be pictured by the client in clear detail. Early recollections are
a series of small mysteries that can be woven together into a tapestry that leads to
an understanding of how we view ourselves, how we see the world, what our life
goals are, what motivates us, what we value and believe in, and what we anticipate
for our future (Clark, 2002; Mosak & Di Pietro, 2006). Adler reasoned that out of
the millions of early memories we might have we select those special memories
that project the essential convictions and even the basic mistakes of our lives. To
a large extent, what we selectively attend to from the past is reflective of what we
believe, how we behave in the present, and our anticipation of the future (Watts,
2015).
Early memories cast light on the “story of our life” because they represent meta-
phors for our current views. From the thousands of experiences we have before the
age of 10, we tend to remember only 6 to 12 memories. By understanding why we
retain these memories and what they tell us about how we see ourselves, others, and
life in the present, it is possible to get a clear sense of our mistaken notions, present
attitudes, social interests, and possible future behavior. Early recollections are spe-
cific instances that clients tell therapists, and they are very useful in understanding
those who are sharing a story (Mosak & Di Pietro, 2006). Exploring early recollec-
tions involves discovering how mistaken notions based on faulty goals and values
continue to create problems in a client’s life. Early recollections serve an organizing
function in understanding the purposefulness of behavior, the style of life, striving
for superiority, holism, and birth order (Clark, 2012).
To tap such recollections, the counselor might proceed as follows: “I would like
to hear about your early memories. Think back to when you were very young, as
early as you can remember (before the age of 10), and tell me something that happened
one time. Be sure to recall something you remember, not something you were told
about by others.” After receiving each memory, the counselor might also ask: “What
part stands out to you? What was the most vivid part of your early memory? If you
played the whole memory like a movie and stopped it at one frame, what would
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112 C H A P T E R F I V E
be happening? Putting yourself in that moment, what are you feeling? What’s your
reaction?” Three memories are usually considered a minimum to assess a pattern,
and some counselors ask for as many as a dozen memories.
Adlerian therapists use early recollections as a projective technique (Clark,
2002; Hays, 2013) and to (a) assess the client’s convictions about self, others, life,
and ethics; (b) assess the client’s stance in relation to the counseling session and the
counseling relationship; (c) verify the client’s coping patterns; and (d) assess individ-
ual strengths, assets, and interfering ideas (Bitter et al., 1998, p. 99). In interpreting
these early recollections, Adlerians may consider questions such as these:
�� What part does the client take in the memory? Is the client an observer
or a participant?
�� Who else is in the memory? What position do others take in relation to
the client?
�� What are the dominant themes and overall patterns of the memories?
�� What feelings are expressed in the memories?
�� Why does the client choose to remember this event? What is the client
trying to convey?
Let’s try this out. Here are three memory stories and some guesses about what these
memories might mean.
Memory 1: “I was 4 years old. We were staying at grandma and grandpa’s
house. I got to sleep in the attic, and it had a neat hole from which I could
spy on the adults below. I could see and hear them, but they could not see
me. I love being sneaky.
Interpretation: I like to (a) be on top of things; (b) know what’s going on—
even if it’s none of my business; and (c) I like to be an observer.
Memory 2: I am 8 years old. It is summer. My father wants to take me
with him to a baseball game, but I am not around. I am off playing where
I should not be, and my mom can’t find me. I miss out on going with my
dad. I cry when I am told, and I am sad.
Interpretation: If I do things I am not supposed to do, even if I am having
fun, I might miss out on something even more fun.
Memory 3: I am in the second or third grade, maybe 8 or 9. I am asked to
come to the blackboard and work out a problem. I remember how to do it
mostly. I get almost to the end, but I cannot complete it. Someone else has
to come up and complete it, and I miss out on getting to the right answer.
I am watching Gary Snitley complete the problem, and I am disappointed
that I didn’t remember it.
Interpretation: There is always someone out there who is smarter than me.
If I am going to do something and get credit for it, I better do it all and do
it right the first time; there is no room for error.
Can you match these tentative interpretations with the details offered in each mem-
ory story?
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A d l E R I A n T H E R A P y 113
Integration and Summary Once material has been gathered from both subjective
and objective interviews with the client, integrated summaries of the data are
developed. Different summaries are prepared for different clients, but common ones
are a narrative summary of the person’s subjective experience and life story; a summary
of family constellation and developmental data; a summary of early recollections,
personal strengths or assets, and interfering ideas; and a summary of coping strategies.
The summaries are presented to the client and discussed in the session, with the client
and the counselor together refining specific points. This information provides the
client with the chance to discuss specific topics and to raise questions.
The Student Manual that accompanies this textbook includes a concrete exam-
ple of the lifestyle assessment as it is applied to the case of Stan. In Case Approach to
Counseling and Psychotherapy (Corey, 2013, chap. 3), Drs. Jim Bitter and Bill Nicoll
present a lifestyle assessment of another hypothetical client, Ruth.
Phase 3: Encourage Self-Understanding and Insight
During this third phase, Adlerian therapists interpret the findings of the
assessment as an avenue for promoting self-understanding and insight. When
Adlerians speak of insight, they are referring to an understanding of the motiva-
tions that operate in a client’s life. Self-understanding is only possible when hid-
den purposes and goals of behavior are made conscious. Adlerians consider insight
as a special form of awareness that facilitates a meaningful understanding within
the therapeutic relationship and acts as a foundation for change. Insight without
action is not enough. Insight is a means to an end, and not an end in itself. People
can make rapid and significant changes without much insight.
Disclosure and well-timed interpretations are techniques that facilitate the pro-
cess of gaining insight. interpretation deals with clients’ underlying motives for
behaving the way they do in the here and now. Adlerian disclosures and interpreta-
tions are concerned with creating awareness of one’s direction in life, one’s goals and
purposes, one’s private logic and how it works, and one’s current behavior.
Adlerian interpretations are suggestions presented tentatively in the form of
open-ended questions that can be explored in the sessions. They are hunches or
guesses, and they often begin with phrases such as “I could be wrong, but I am won-
dering if … ,” “Could it be that … ,” or “Is it possible that …” Because interpretations
are presented in this manner, clients are not led to defend themselves, and they feel
free to discuss and even argue with the counselor’s hunches and impressions.
Through this process, both counselor and client eventually come to understand the
client’s motivations, the ways in which these motivations are now contributing to
the maintenance of the problem, and what the client can do to correct the situation.
During this phase of therapy, the counselor helps the client understand the limita-
tions of the style of life the client has chosen.
Phase 4: Reorientation and Reeducation
The final stage of the therapeutic process is the action-oriented phase
known as reorientation and reeducation: putting insights into practice. This phase
focuses on helping clients discover a new and more functional perspective. Clients
are both encouraged and challenged to develop the courage to take risks and make
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114 C H A P T E R F I V E
changes in their life. During this phase, clients can choose to adopt a new style of life
based on the insights they gained in the earlier phases of therapy. More commonly,
clients figure out how to reorient their current style of living to the useful side of
life, increasing their community feeling and social interest. The useful side involves
a sense of belonging and being valued, having an interest in others and their welfare,
courage, the acceptance of imperfection, confidence, a sense of humor, a willingness
to contribute, and an outgoing friendliness. The useless side of life is characterized
by self-absorption, withdrawal from life tasks, self-protection, or acts against one’s
fellow human beings. People acting on the useless side of life become less functional
and are more susceptible to psychopathology. Adlerian therapy stands in opposi-
tion to self-depreciation, isolation, and retreat, and it seeks to help clients gain cour-
age and to connect to strengths within themselves, to others, and to life.
reorientation involves shifting rules of interaction, process, and motivation.
These shifts are facilitated through changes in awareness, which often occur
during the therapy session and which are transformed into action outside of the
therapy office (Bitter & Nicoll, 2004). In addition, especially at this phase of therapy,
Adlerians focus on reeducation (see the section Therapeutic Goals). Throughout this
phase, no intervention is more important than encouragement.
The Encouragement Process Encouragement is the most distinctive Adlerian
procedure, and it is central to all phases of counseling and therapy. It is especially
important as people consider change in their lives. encouragement literally means
“to build courage.” Encouragement is a process of increasing the courage needed
for a person to face difficulties in life (Carlson & Englar-Carlson, 2013). Courage
develops when people become aware of their strengths, when they feel they belong
and are not alone, and when they have a sense of hope and can see new possibilities
for themselves and their daily living. Therapists help clients focus on their resources
and strengths and to have faith that they can make life changes, even though life
can be difficult. Milliren, Evans, and Newbauer (2007) consider encouragement key
in promoting and activating social interest. They add that encouragement is the
universal therapeutic intervention for Adlerian counselors, that it is a fundamental
attitude, or way of being, rather than a technique. Because clients often do not
recognize or accept their positive qualities, strengths, or internal resources, one of
the counselor’s main tasks is to help them do so.
Adlerians believe discouragement is the basic condition that prevents people
from functioning, and they see encouragement as the antidote. As a part of the
encouragement process, Adlerians use a variety of relational, cognitive, behavioral,
emotional, and experiential techniques to help clients identify and challenge self-
defeating cognitions, generate perceptional alternatives, and make use of assets,
strengths, and resources (Ansbacher & Ansbacher, 1964; Watts, 2015).
Encouragement takes many forms, depending on the phase of the counseling
process. In the relationship phase, encouragement results from the mutual respect
the counselor seeks to engender. Here is an opening intervention focusing on
encouragement:
Client: I almost didn’t come . . .
Counselor: . . . but you did.
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A d l E R I A n T H E R A P y 115
Client: Yes, but I just don’t know. Maybe it would have been better
just to end it all, not even bother.
Counselor: So you are in a lot of pain, even thinking about ending it all,
but still you came. That took a lot of courage, How did you
manage to summon that courage and then act on it?
In the assessment phase, which is partially designed to illuminate personal strengths,
clients are encouraged to recognize that they are in charge of their own lives and can
make different choices based on new understandings.
During reorientation, encouragement comes when new possibilities are gener-
ated and when clients are acknowledged and affirmed for taking positive steps to
change their lives for the better. This later intervention focused on encouragement
has a triumphant tone:
Counselor: Let me see if I understand this. You were in a familiar
family setting. Your father was berating you about a minor
difference of opinion, really trying to push your buttons, and
you managed not only to stay calm but also offered to help
him sort some materials in his office. You must feel so proud
of yourself, triumphant even. What a transformation of your
normal interactions.
Client: Yes, and I even walked away feeling I had made a difference
in his life. I did not lose my temper. I did not strike back. I
actually just heard him in a different way, knew he needed
to feel right and important, and when I let that happen,
everything changed between us.
Counselor: You even know the steps that got you there.
Client: Yes, I do.
Counselor: Achieving a change in long-held family patterns is one of the
hardest things to attain. You have a right to feel delighted.
Change and the Search for New Possibilities During the reorientation phase
of counseling, clients make decisions and modify their goals. They are encouraged
to act as if they were the people they want to be, which can serve to challenge self-
limiting assumptions. Clients are asked to catch themselves in the process of repeating
old patterns that have led to ineffective behavior (Watts, 2015). Commitment is
an essential part of reorientation. If clients hope to change, they must be willing
to set tasks for themselves in everyday life and do something specific about their
problems. In this way, clients translate their new insights into concrete actions.
Bitter and Nicoll (2004) emphasize that real change happens between sessions, and
not in therapy itself. They state that arriving at a strategy for change is an important
first step, and stress that it takes courage and encouragement for clients to apply
what they have learned in therapy to daily living.
This action-oriented phase is a time for solving problems and making decisions.
The counselor and the client consider possible alternatives and their consequences,
evaluate how these alternatives will meet the client’s goals, and decide on a specific
course of action. The best alternatives and new possibilities are those generated
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116 C H A P T E R F I V E
by the client, and the counselor must offer the client a great deal of support and
encouragement during this stage of the process.
Making a Difference Adlerian therapists seek to make a difference in the lives of
their clients. That difference may be manifested by a change in behavior or attitude
or perception. Adlerians use many different techniques to promote change, some of
which have become common interventions in other therapeutic models. Techniques
that go by the names of immediacy, advice, humor, silence, paradoxical intention,
acting as if, catching oneself, the push-button technique, externalization, reauthoring,
avoiding the traps, confrontation, use of stories and fables, early recollection analysis,
lifestyle assessment, encouraging, task setting and commitment, giving homework,
and terminating and summarizing have all been used (Carlson & Johnson, 2016;
Carlson et al., 2006; Dinkmeyer & Sperry, 2000; Disque & Bitter, 1998; Mozdzierz,
Peluso, & Lisiecki, 2009). Contemporary Adlerian practitioners are diverse in their
styles of counseling (Maniacci, 2012; Watts, 2015), and they can creatively employ
a wide range of other techniques, as long as these methods are philosophically
consistent with the basic theoretical premises of Adlerian psychology. Adlerians are
pragmatic when it comes to using techniques that are appropriate for a given client.
In general, however, Adlerian practitioners focus on motivation modification more
than behavior change and encourage clients to make holistic changes on the useful
side of living.
All therapy is a cooperative effort, and making a difference depends on the
therapist’s ability to win the client’s cooperation. Let’s focus on one technique tra-
ditionally associated with Adlerian counseling to see what it looks like in action.
Harold Mosak, a highly respected therapist, uses the push-button technique with cli-
ents who know they are depressed but feel that the depression controls them and
that nothing can be done. The goal of this technique is to help clients become aware
of their role in contributing to their unpleasant feelings. Typically, clients are asked
to re-create an unpleasant memory, which is then followed by recalling a pleasant
memory (Watts, 2015).
Counselor: I am sure we can end your depression rather easily. Let’s start
with what you really need to do with your life [the set up].
Client: Wait a minute. If you can get rid of my depression easily, let’s
do it.
Counselor: Well, OK. You will have to close your eyes. I want you to
think about the worst, most awful thing that has happened
to you recently. When you have it in mind, I want you to
raise your right hand. [The client pauses for a few moments and
then raises his hand.] Now, I would like you to add the feeling
you feel when you think about this horrible part of your life.
[Taking the client’s right hand, the counselor presses the index finger
onto the client’s leg.] We will call this your depression button.
Now, I want you to think about the best thing that has
happened to you or could happen to you or you would love
to have happen to you. Raise your left hand when you know
what that is.
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A d l E R I A n T H E R A P y 117
Client: I can’t really think of anything.
Counselor: You may have to go back to an earlier time to remember a
really good time that you would like to have in your life now,
but I know you can do it. [A minute later the man raises his left
hand.] Now, add the feeling you have thinking about that
happy time. [Taking the client’s left hand, the counselor presses the
index finger onto the client’s other leg.]
So you have a depression button on your right leg, and
you can push it and think about everything horrible, awful,
or worse, and feel depressed. Or you can push the happy
button on the other leg, think about wonderful things or
events or people, and feel happy. If you come in next week
and tell me you have felt depressed, I will simply ask you why
you decided to push the depression button rather than the
happy button.
The push-button technique recognizes that “control” is a major theme in
depression, and this intervention is designed to help the client regain a sense of con-
trol over the negative feelings that seem overwhelming. An effective way of using this
technique may be to give the client, especially a child or an adolescent, an actual
push-button to carry in his or her pocket as a physical reminder.
Areas of Application
Adler anticipated the future direction of the helping professions by calling
upon therapists to become social activists and by addressing the prevention and
remediation of social conditions that were contrary to social interest and resulted
in human problems. Adler’s own experiences of discrimination and the influence
of social inequality are well represented in his writings. Adler’s pioneering efforts
on prevention services in mental health led him to increasingly advocate for the
role of Individual Psychology in schools and families. Because Individual Psychol-
ogy is based on a growth model, not a medical model, it is applicable to such var-
ied spheres of life as child guidance; parent–child counseling; couples counseling;
family counseling and therapy; group counseling and therapy; individual counsel-
ing with children, adolescents, and adults; cultural conflicts; correctional and reha-
bilitation counseling; and mental health institutions. Adler’s basic ideas have been
incorporated into the practices of school psychology, school counseling, the com-
munity mental health movement, and parent education. Adlerian principles have
been widely applied to substance abuse programs, social problems to combat pov-
erty and crime, problems of the aged, school systems, religion, and business. Adle-
rian ideas also have had widespread international application and acceptance (see
Fall and Winter 2012 special issues of the Journal of Individual Psychology for interna-
tional perspectives on Individual Psychology).
Application to Family Counseling With its emphasis on the family constellation,
holism, and the freedom of the therapist to improvise, Adler’s approach contributed
to the foundation of the family therapy perspective. Adlerians working with families
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118 C H A P T E R F I V E
focus on the family atmosphere, the family constellation, and the interactive goals
of each member (Bitter, 2014). The family atmosphere is the climate characterizing
the relationship between the parents and their attitudes toward life, gender roles,
decision making, competition, cooperation, dealing with conflict, responsibility,
and so forth. This atmosphere, including the role models the parents provide,
influences the children as they grow up. The therapeutic process seeks to increase
awareness of the interaction of the individuals within the family system. Those
who practice Adlerian family therapy strive to understand the goals, beliefs, and
behaviors of each family member and the family as an entity in its own right.
Application to Group Counseling Adler and his coworkers used a group approach
in their child guidance centers in Vienna as early as 1921 (Dreikurs, 1969). Dreikurs
extended and popularized Adler’s work with groups and used group psychotherapy
in his private practice for more than 40 years. Although Dreikurs introduced group
therapy into his psychiatric practice as a way to save time, he quickly discovered
some unique characteristics of groups that made them an effective way of helping
people change. Inferiority feelings can be challenged and counteracted effectively
in groups, and the mistaken concepts and values that are at the root of social and
emotional problems can be deeply influenced because the group is a value-forming
agent (Sonstegard & Bitter, 2004).
The rationale for Adlerian group counseling is based on the premise that our
problems are mainly of a social nature. The group provides the social context in
which members can develop a sense of belonging, social connectedness, and com-
munity. Sonstegard and Bitter (2004) write that group participants come to see that
many of their problems are interpersonal in nature, that their behavior has social
meaning, and that their goals can best be understood in the framework of social
purposes. Group counseling is particularly helpful in promoting social interest. A
core therapeutic factor is the role of altruism, which is the process of helping others
in the group. The process of developing group cohesion parallels social interest (pro-
moting the social welfare, in this case of the group) and community feeling (feeling
connected and closer to the group itself), which are primary goals of Adlerian ther-
apy. For example, in a men’s group, one of the core goals is often helping discour-
aged and isolated men feel useful to others (building altruism) and connected to
fellow men. While this group process is building, group members are also building
their social interest by feeling connected to something bigger than themselves.
The use of early recollections is a unique feature of Adlerian group counseling.
As mentioned earlier, from a series of early memories, individuals can get a clear
sense of their mistaken notions, current attitudes, social interests, and possible
future behavior. Through the mutual sharing of these early recollections, members
develop a sense of connection with one another, and group cohesion is increased.
The group becomes an agent of change because of the improved interpersonal rela-
tionships among members and the emergence of hope.
Especially valuable is the way Adlerian group counselors implement action
strategies at each of the group sessions and especially during the reorientation stage
when new decisions are made and goals are modified. To challenge self-limiting
assumptions, members are encouraged to act as if they were the persons they want
to be. They are asked to “catch themselves” in the process of repeating old patterns
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A d l E R I A n T H E R A P y 119
that have led to ineffective or self-defeating behavior. The members come to appre-
ciate that if they hope to change, they need to set tasks for themselves, apply group
lessons to daily life, and take steps in finding solutions to their problems. This final
stage is characterized by group leaders and members working together to challenge
erroneous beliefs about self, life, and others. During this stage, members are consid-
ering alternative beliefs, behaviors, and attitudes.
Adlerian group counseling can be considered a brief approach to treatment.
The core characteristics associated with brief group therapy include rapid establish-
ment of a strong therapeutic alliance, clear problem focus and goal alignment, rapid
assessment, emphasis on active and directive therapeutic interventions, a focus on
strengths and abilities of clients, an optimistic view of change, a focus on both the
present and the future, and an emphasis on tailoring treatment to the unique needs
of clients in the most time-efficient manner possible (Carlson et al., 2006).
Adlerian brief group therapy is addressed by Sonstegard, Bitter, Pelonis-Peneros,
and Nicoll (2001). For more on the Adlerian approach to group counseling, refer to
Theory and Practice of Group Counseling (Corey, 2016, chap. 7) and Sonstegard and
Bitter (2004).
Adlerian Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
Carlson and Englar-Carlson (2013) believe that Adlerian theory is well
suited to counseling diverse populations and doing social justice work. They state
that Adlerian therapy not only focuses acutely on multicultural and social justice
issues but is “alive, well, and poised to address the concerns of a contemporary
global society” (p. 94).
Although the Adlerian approach is called Individual Psychology, its focus is on
the person in a social context. Clients are encouraged to define themselves within
their social environments and to understand how those environments influence
their lifestyle and health. Adlerians allow broad concepts of age, ethnicity, lifestyle,
sexual/affectional orientations, and gender differences to emerge in therapy, and
these issues are then addressed (Carlson & Englar-Carlson, 2013). The therapeutic
process is grounded within a client’s culture and worldview rather than attempting
to fit clients into preconceived models.
In their analysis of the various theoretical approaches to counseling, Arciniega
and Newlon (2003) state that Adlerian theory holds a great deal of promise for
addressing diversity issues. They note a number of characteristics of Adlerian the-
ory that are congruent with the values of many racial, cultural, and ethnic groups,
including the emphasis on understanding the individual in a familial and sociocul-
tural context; the role of social interest and contributing to others; and the focus
on belonging and the collective spirit. Cultures that stress the welfare of the social
group and emphasize the role of the family will find the basic assumptions of Adle-
rian psychology to be consistent with their values.
Adlerian therapists tend to focus on cooperation and socially oriented val-
ues as opposed to competitive and individualistic values. This makes the Adlerian
approach well-suited for our increasingly multicultural and pluralistic society.
LO12
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120 C H A P T E R F I V E
Native American clients, for example, tend to value cooperation over competition.
One such client told a story about a group of boys who were in a race. When one
boy got ahead of the others, he would slow down and allow the others to catch up,
and they all made it to the finish line at the same time. Although the coach tried
to explain that the point of the race was for an individual to finish first, these boys
were socialized to work together cooperatively as a group. Adlerian therapy is easily
adaptable to cultural values that emphasize community.
Adlerian practitioners are not wedded to any particular set of procedures and
may apply a range of cognitive and action-oriented techniques to helping clients
explore their practical problems in a cultural context. Adlerians are conscious of the
value of adapting their techniques to each client’s situation, but most of them do
conduct a lifestyle assessment that is heavily focused on the structure and dynam-
ics within the client’s family. Because of their cultural background, many clients
have been conditioned to respect their family heritage and to appreciate the impact
of their family on their own personal development. It is essential that counselors
be sensitive to the conflicting feelings and struggles of their clients. If counselors
demonstrate an understanding of these cultural values, it is likely that these clients
will be receptive to an exploration of their lifestyle. Such an exploration will involve
a detailed discussion of their own place within their family.
It should be noted that Adlerians investigate culture in much the same way that
they approach birth order and family atmosphere. Culture is a vantage point from
which life is experienced and interpreted; it is also a background of values, history,
convictions, beliefs, customs, and expectations that must be addressed by the indi-
vidual. Culture provides a way of grasping the subjective and experiential perspec-
tive of an individual. Although culture influences each person, it is expressed within
each individual differently, according to the perception, evaluation, and interpreta-
tion of culture that the person holds. Adlerians find in different cultures opportuni-
ties for viewing the self, others, and the world in multidimensional ways.
Shortcomings From a Diversity Perspective
As is true of most Western models, the Adlerian approach tends to focus on the self
as the locus of change and responsibility. Because other cultures may have differ-
ent conceptions, this primary emphasis on changing the autonomous self may be
problematic for many clients. Assumptions about the Western nuclear family are
built into the Adlerian concepts of birth order and family constellation. For people
brought up in extended family contexts, some of these ideas may be less relevant or
at least may need to be reconfigured.
Adlerian theory has some potential drawbacks for clients from those cultures
who are not interested in exploring past childhood experiences, early memories,
family experiences, and dreams. This approach also has limited effectiveness with
clients who do not understand the purpose of exploring the details of a lifestyle
analysis when dealing with life’s current problems (Arciniega & Newlon, 2003). In
addition, the culture of some clients may contribute to their viewing the counselor
as the “expert” and expecting that the counselor will provide them with solutions to
their problems. For these clients, the role of the Adlerian therapist may pose prob-
lems because Adlerian therapists are not experts in solving other people’s problems.
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A d l E R I A n T H E R A P y 121
Instead, they view it as their function to collaboratively teach people alternative
methods of coping with life concerns.
Many clients who have pressing problems are likely to be hesitant to discuss
areas of their lives that they may not see as connected to the struggles that bring
them into therapy. Individuals may believe that it is inappropriate to reveal family
information. On this point Carlson and Carlson (2000) suggest that a therapist’s
sensitivity and understanding of a client’s culturally constructed beliefs about dis-
closing family information are critical. If the therapist is able to demonstrate an
understanding of a client’s cultural values, it is likely that this person will be more
open to the assessment and treatment process.
T he basic aims of an Adlerian therapist working with Stan are fourfold and correspond to the four
stages of counseling: (1) establishing and maintaining
a good working relationship with Stan, (2) exploring
Stan’s dynamics, (3) encouraging Stan to develop in-
sight and understanding, and (4) helping Stan see new
alternatives and make new choices.
To develop mutual trust and respect, I pay close
attention to Stan’s subjective experience and attempt
to get a sense of how he has reacted to the turning
points in his life. During the initial session, Stan re-
acts to me as the expert who has the answers. He is
convinced that when he makes decisions he generally
ends up regretting the results. Stan approaches me out
of desperation. Because I view counseling as a relation-
ship between equals, I initially focus on his feeling of
being unequal to most other people. A good place to
begin is exploring his feelings of inferiority, which he
says he feels in most situations. The goals of counsel-
ing are developed mutually, and I avoid deciding for
Stan what his goals should be. I also resist giving Stan
the simple formula he is requesting.
I prepare a lifestyle assessment based on a ques-
tionnaire that taps information about Stan’s early
years, especially his experiences in his family. (See the
Student Manual for Theory and Practice of Counseling and
Psychotherapy [Corey, 2017] for a complete description of
this lifestyle assessment form as it is applied to Stan.)
This assessment includes a determination of whether
he poses a danger to himself because Stan did mention
suicidal ideation. During the assessment phase, which
might take a few sessions, I explore with Stan his social
relationships, his relationships with members of his
family, his work responsibilities, his role as a man, and
his feelings about himself. I place considerable empha-
sis on Stan’s goals in life and his priorities. I do not
pay a great deal of attention to his past, except to show
him the consistency between his past and present as he
moves toward the future.
As an Adlerian counselor, I place value on explor-
ing early recollections as a source of understanding his
goals, motivations, and values. I ask Stan to report his
earliest memories.
Stan: I was about 6, I went to school, and I was scared
of the other kids and the teacher. When I came
home, I cried and told my mother I didn’t want
to go back to school. She yelled at me and called
me a baby. After that I felt horrible and even more
scared.
Another of Stan’s early recollections was at age 8:
Stan: My family was visiting my grandparents. I was
playing outside, and some neighborhood kid hit
me for no reason. We started fighting, and my
mother came out and scolded me for being such
a rough kid. She wouldn’t believe me when I told
her he started the fight. I felt angry and hurt that
she didn’t believe me.
Based on these early recollections, I suggest that Stan
sees life as frightening and unpredictably hostile and
that he feels he cannot count on women; they are likely
to be harsh, unbelieving, and uncaring.
Having gathered the data based on the life-
style assessment about his family constellation and
his early recollections, I assist Stan in the process of
Adlerian Therapy Applied to the Case of Stan
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See the DVD for Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes
(Session 3 on Adlerian therapy) for a demon-
stration of my approach to counseling Stan by
focusing on his early recollections.
summarizing and interpreting this information. I
give particular attention to identifying basic mis-
takes, which are faulty conclusions about life and self-
defeating perceptions. Here are some of the mistaken
conclusions Stan has reached:
�� “I must not get close to people, because they will
surely hurt me.”
�� “Because my own parents didn’t want me and
didn’t love me, I’ll never be desired or loved by
anybody.”
�� “If only I could become perfect, maybe people
would acknowledge and accept me.”
�� “Being a man means not showing emotions.”
The information I summarize and interpret leads
to insight and increased self-understanding on Stan’s
part. He gains increased awareness of his need to con-
trol his world so that he can keep painful feelings in
check. He sees more clearly some of the ways he tries to
gain control over his pain: through the use of alcohol,
avoiding interpersonal situations that are threatening,
and being unwilling to count on others for psycho-
logical support. Through continued emphasis on his
beliefs, goals, and intentions, Stan comes to see how
his private logic is inaccurate. In his case, a syllogism
for his style of life can be explained in this way: (1) “I
am unloved, insignificant, and do not count”; (2) “The
world is a threatening place to be, and life is unfair”;
(3) “Therefore, I must find ways to protect myself and
be safe.” During this phase of the process, I make in-
terpretations centering on his lifestyle, his current di-
rection, his goals and purposes, and how his private
logic works. Of course, Stan is expected to carry out
homework assignments that assist him in translating
his insights into new behavior. In this way he is an ac-
tive participant in his therapy.
In the reorientation phase of therapy, Stan and
I work together to consider alternative attitudes,
beliefs, and actions. By now Stan sees that he does
not have to be locked into past patterns, feels encour-
aged, and realizes that he has the power to change
his life. He accepts that he will not change merely
by gaining insights and knows that he will have to
make use of these insights by carrying out an action-
oriented plan. Stan begins to feel that he can create
a new life for himself and not remain the victim of
circumstances.
Questions for Reflection
�� What are some ways you would attempt to estab-
lish a relationship with Stan based on trust and
mutual respect? Can you imagine any difficulties
in developing this relationship with him?
�� What aspects of Stan’s lifestyle particularly inter-
est you? In counseling him, how would these be
explored?
�� The Adlerian therapist identified four of Stan’s
mistaken conclusions. Can you identify with any
of these basic mistakes? If so, do you think this
would help or hinder your therapeutic effective-
ness with him?
�� How might Stan’s cultural identity and context
be assessed, and what might be the relationship to
his presenting concerns?
�� How might you assist Stan in discovering his
social interest and going beyond a preoccupation
with his own problems?
�� What strengths and resources in Stan might you
draw on to support his determination and com-
mitment to change?
Adlerian Therapy Applied to the Case of Gwen*
122 C H A P T E R F I V E
As the eldest child, Gwen learned early on that she was responsible not only for herself but for all
those in need around her as well. She often sacrificed
her own desires in an effort to please of others. She
knows how to stand up for herself, but too often takes
on the role of helper and loses her sense of personal
meaning and identity.
* Dr. Kellie Kirksey writes about her ways of thinking and practicing from an Adlerian perspective and applying this model to Gwen.
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Adlerian Therapy Applied to the Case of Gwen*
Gwen: I have played by everyone’s rules for so long,
and now I am just tired. I just can’t seem to win.
Therapist: If I were facing everything you are facing,
I too would be tired and sad . . . and sometimes
irritated.
I want to normalize Gwen’s experience because I know
all too well that being an African American woman jug-
gling multiple roles carries with it additional stresses
and burdens.
Therapist: Is it safe to say that your life feels out of
control?
Gwen: Yes. I can’t remember the last time I felt I was
really in the driver’s seat.
Therapist: So, let’s see. You take care of your spouse,
your mother, and check in on your siblings—
which, by the way, you have been doing since you
were a child. Even though your children are gone,
you still listen to their needs on a regular basis
and help out in any way that you can. You seldom
if ever see your friends (no time), and you cannot
seem to concentrate on your work enough to feel
productive. Did I understand you correctly?
Gwen: Yes. You got it all.
Therapist: I am not even sure I am close to getting it
all, because all of that is enough to overload anyone.
Gwen: Yes, I am totally overloaded. I have to handle
all of this, get things done, and get life back to
normal. But I just can’t get focused.
Therapist: Yes. There is so much. You get distracted;
you start running without knowing where you are
going; you worry; and the cycle continues.
Gwen: I just have so many problems.
Therapist: What would you be doing with your life if
you did not have all of these problems in your life?
How would your life be different? [Asking “The
Question.”]
Gwen: That’s just it: I don’t know anymore. Well, I
wouldn’t feel so depressed anymore. I would hope
for a better life with my husband and friends, but
I don’t even know if that is possible.
Gwen comes to the next session looking some-
what more relaxed than at our first session. I ask her
what accounts for this, and she says that really every-
thing is about the same, but she felt understood at the
last session, so she has some hope. I thank her for tell-
ing me and congratulate her on the courage she has
shown in coming to therapy.
Therapist: Gwen, I would like to get to know you
a little better, to have a sense of what you have
learned from life. Would it be OK if I ask you
about some important parts of your life so far?
Gwen: Yes, of course.
During this session, I begin to ask Gwen about the
story of her life, using the tools Adlerians include in
a lifestyle assessment. I ask about her family constel-
lation, including descriptions of and the relationship
between her parents. I ask which of her siblings was
most different from her and in what way? Which one
was like her and in what way? And what was she like as
a child? In each of these descriptions, Gwen tells me
about the early meaning she attached to her family
life. During this discussion she tells me about being
molested as a child by an older cousin and her deter-
mination to protect her siblings from a similar fate.
In the next session, Gwen tells me about her devel-
opmental history, addressing each one of Adler’s three
tasks of life. She has always been a person who had just
a few close friends, and she tends to take charge. “I guess
some of my friends think I am a bit bossy. I know my sis-
ter does for sure, and she is still my best friend.” Gwen
has always worked, first in the home, and then increas-
ingly out in the world. She had her first real job when
she was 14, having lied about her age, so she could work
at a neighborhood restaurant. She has always taken care
of other people, even while going to college—and now,
even while she has heavy demands at her work. Her hus-
band is a community activist. Ron is the only man with
whom she has ever been in love. She feels they are grow-
ing apart, but they handle it by both staying busy. It is
easy to hear in her stories how responsible for others she
feels, how exhausted she must be, and how much of her-
self gets lost in the daily struggles.
Therapist: The struggles you mention are hard
enough by themselves. But you also mentioned
dealing with experiences of racism and sexism.
Can you tell me about some of the particular
challenges you have had to face as an African
American woman?
A d l E R I A n T H E R A P y 123
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Summary and Evaluation
Summary
Adler was far ahead of his time, and most contemporary therapies have incorpo-
rated at least some of his ideas. Individual Psychology assumes that people are
motivated by social factors; are responsible for their own thoughts, feelings, and
actions; are the creators of their own lives, as opposed to being helpless victims;
and are impelled by purposes and goals, looking more toward the future than back
to the past.
The basic goal of the Adlerian approach is to help clients identify and change
their mistaken beliefs about, self, others, and life and thus to participate more fully
in a social world. Clients are not viewed as psychologically sick, but as discouraged.
The therapeutic process helps individuals become aware of their patterns and make
some basic changes in their style of living, which lead to changes in the way they feel
and behave. The role of the family in the development of the individual is empha-
sized. Therapy is a cooperative venture that challenges clients to translate their
insights into action in the real world. Contemporary Adlerian theory is an integra-
tive approach, combining cognitive, constructivist, existential, psychodynamic, rela-
tional, and systems perspectives. Some of these common characteristics include an
I, too, am an African American woman, but I cannot
assume that my own experiences are similar to hers. I
have to hear what meaning she personally associates
with race and gender, which are additional tasks of life
she must address every day of her existence. I want to
know what her biggest challenge is as a member of her
culture as well as her greatest strength and points of
cultural pride.
Toward the end of the session, I ask Gwen to pre-
pare a list of early recollections for our next session.
I ask her to remember six or more stories that hap-
pened before she was 8 years old. I want her to think of
the event like a moving picture and stop it at a single
frame: What is happening in that frame, and what is
she feeling? What is her reaction to what happened? If
this were a newspaper story, what would be the head-
line? These memories will most likely confirm what I
am already learning about Gwen, and they will help
me identify the convictions and beliefs, some of which
may be faulty, that guide her life.
Lifestyle assessment is a way of investigating the
client’s unique approach to the life tasks of love, friend-
ship, and work. It is filled with meaning and identity
and convictions and beliefs. It also contains the traits
that make up the individual’s internal resources, the
motivations for both feelings and behaviors, and the
foundation for where life might develop from here.
The golden rule of Individual Psychology is that “ev-
erything can be different.” What difference does Gwen
want to make in her life now?
Questions for Reflection
�� What are your thoughts about asking Gwen to
identify some of her early recollections? Is this
kind of ancient history really important in how an
individual develops a lifestyle? Why do we remem-
ber these things?
�� Gwen wants more suggestions from her therapist.
If you were her therapist, how would you intervene
with her when she wants more direction from you?
�� Encouragement is a foundational technique of
Adlerian therapy. Can you identify any encourag-
ing behaviors by the therapist? What value do you
place on encouragement? What is the difference
between encouragement and praise?
�� How interested would you be in getting informa-
tion from Gwen about issues of race and culture?
�� What additional Adlerian technique would you
use if you were counseling Gwen? What would
your aim be in making this intervention?
124 C H A P T E R F I V E
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A d l E R I A n T H E R A P y 125
emphasis on establishing a respectful client–therapist relationship, an emphasis on
clients’ strengths and resources, and an optimistic and future orientation.
Contributions of the Adlerian Approach
A strength of the Adlerian approach is its flexibility and its integrative nature.
Adlerian therapists are resourceful and flexible in drawing on many methods, which
can be applied to a diverse range of clients in a variety of settings and formats. They
tend to be theoretically consistent and technically eclectic (Watts, 2015). Therapists
are mainly concerned with doing what is in the best interests of clients rather than
squeezing clients into one theoretical framework (Carlson et al., 2006).
Another contribution of the Adlerian approach is that it is suited to brief, time-
limited therapy. Adler was a proponent of time-limited therapy, and the techniques
used by many contemporary brief therapeutic approaches are very similar to inter-
ventions created by or commonly used by Adlerian practitioners (Carlson et al.,
2006). Adlerian therapy and contemporary brief therapy have in common a num-
ber of characteristics, including quickly establishing a strong therapeutic alliance, a
clear problem focus and goal alignment, rapid assessment and application to treat-
ment, an emphasis on active and directive intervention, a psychoeducational focus,
a present and future orientation, a focus on clients’ strengths and abilities and an
optimistic expectation of change, and a time sensitivity that tailors treatment to the
unique needs of the client (Carlson et al., 2006; Hoyt, 2015). According to Mosak
and Di Pietro (2006), early recollections are a significant assessment intervention
in brief therapy. They claim that early recollections are often useful in minimizing
the number of therapy sessions. This procedure takes little time to administer and
interpret and provides a direction for therapists to pursue.
Bitter and Nicoll (2000) identify five characteristics that form the basis for an
integrative framework in brief therapy: time limitation, focus, counselor directive-
ness, symptoms as solutions, and the assignment of behavioral tasks. Bringing a
time-limitation process to therapy conveys to clients the expectation that change
will occur in a short period of time. When the number of sessions is specified, both
client and therapist are motivated to stay focused on desired outcomes and to work
as efficiently as possible. Because there is no assurance that a future session will
occur, brief therapists tend to ask themselves this question: “If I had only one ses-
sion to be useful in this person’s life, what would I want to accomplish?” (p. 38).
It is difficult to overestimate the contributions of Adler to contemporary thera-
peutic practice. In many ways, I believe Adler’s influence on current practice is greater
than that of Freud. Many of Adler’s ideas were revolutionary and far ahead of his
time. His influence went beyond counseling individuals, extending into the commu-
nity mental health movement (Ansbacher, 1974). Abraham Maslow, Viktor Frankl,
Rollo May, Paul Watzlawick, Karen Horney, Erich Fromm, Aaron T. Beck, and Albert
Ellis have all acknowledged their debt to Adler. Both Frankl and May see him as a
forerunner of the existential movement because of his position that human beings
are free to choose and are entirely responsible for what they make of themselves. This
view also makes him a forerunner of the subjective approach to psychology, which
focuses on the internal determinants of behavior: values, beliefs, attitudes, goals,
interests, personal meanings, subjective perceptions of reality, and strivings toward
LO13
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126 C H A P T E R F I V E
self-realization. Bitter (2008; Bitter, Robertson, Healey, & Cole, 2009) has drawn
attention to the link between Adlerian thinking and feminist therapy approaches.
One of Adler’s most important contributions was his influence on other therapy
systems. Many of his basic ideas have found their way into most of the other psy-
chological schools, a few of which include existential therapy, cognitive behavior
therapy, rational emotive behavior therapy, reality therapy, solution-focused brief
therapy, feminist therapy, and family therapy. Adlerian psychology is a phenomeno-
logical, holistic, optimistic, and socially embedded theory based on basic assump-
tions that have been woven into various theories of counseling (Carlson & Johnson,
2016; Maniacci et al., 2014). In many respects, Adler seems to have paved the way
for current developments in both the cognitive and constructivist therapies (Watts,
2012, 2015). Adlerians’ basic premise is that if clients can change their thinking,
then they can change their feelings and behavior. A study of contemporary counsel-
ing theories reveals that many of Adler’s notions have reappeared in these modern
approaches with different nomenclature, and often without giving Adler the credit
that is due to him (Watts, 2015). One example of this is found in the emergence
of the positive psychology movement, which calls for an increased study of hope,
courage, contentment, happiness, well-being, perseverance, resilience, tolerance, and
personal resources. Adler clearly addressed major themes associated with positive
psychology long before this approach appeared on the therapeutic scene (Watts,
2012). It is clear that there are significant linkages between Adlerian theory and most
of the present-day theories, especially those that view the person as purposive, self-
determining, and striving for growth. Carlson and Englar-Carlson (2013) assert that
Adlerians face the challenge of continuing to develop their approach so that it meets
the needs of contemporary global society: “Whereas Adlerian ideas are alive in other
theoretical approaches, there is a question about whether Adlerian theory as a stand-
alone approach is viable in the long term” (p. 124). With so many Adlerian concepts
co-opted by other models, these authors believe that for the Adlerian model to sur-
vive and thrive it will be necessary to find ways to strive for significance.
Limitations and Criticisms of the Adlerian Approach
Adler had to choose between devoting his time to formalizing his theory
and teaching others the basic concepts of Individual Psychology. He placed prac-
ticing therapy and teaching before organizing and presenting a well-defined and
systematic theory. Many of Adler’s ideas are vague and general, which makes it dif-
ficult to conduct research on some concepts (Carlson & Johnson, 2016). His writ-
ten presentations are often difficult to follow, and many of them are transcripts of
lectures he gave. Adler’s global reach was unprecedented, but he did not attend to
the way his work was translated. Although he was brilliant in many ways, he was not
scholarly (Maniacci, 2012).
Self-Reflection and Discussion Questions
1. What are some of your earliest memories? Identify one specific early
memory and reflect on the significance this early recollection has for
you. What value do you see in the Adlerian technique of having indi-
viduals recall their earliest memories?
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A d l E R I A n T H E R A P y 127
2. Adlerians contend that each of us has a unique lifestyle, or personality,
that starts to develop in early childhood to compensate for and over-
come some perceived inferiority. How does this key concept apply to
you? In what ways have you felt inferior in the past, and how have you
dealt with it? Do you see any potential connection between your strug-
gle with basic inferiority and your accomplishments?
3. From an Adlerian perspective, individuals are best understood by
looking at their future strivings. How are your goals influencing what
you are doing now? How do you think your past has influenced your
future goals? In what ways can you apply this purposive, goal-oriented
approach in your work as a therapist?
4. Adlerians emphasize the family constellation. Reflect on what it was
like for you to grow up in your family. How would you characterize
your relationship with each of your siblings? What did you learn about
yourself and others through your early family experiences?
5. Social interest is a central concept in the Adlerian approach. What value
do you place on social interest in your own life? In what ways do you
think you could assist your clients in developing their social interest?
Where to Go From Here
Visit CengageBrain.com or watch the DVD for Integrative Counseling: The Case of Ruth
and Lecturettes, Session 6 (“Cognitive Focus in Counseling”), which illustrates Ruth’s
striving to live up to expectations and measure up to perfectionist standards. In this
therapy session with Ruth, you will see how I draw upon cognitive concepts and
apply them in practice.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) by going to www
.counseling.org and clicking on the Resource button, and then the Podcast Series.
For Chapter 5, look for Podcast 11, Adlerian Therapy, by Dr. Jon Carlson.
Other Resources
Videos from Psychotherapy.net demonstrate Adlerian therapy with adults, families,
and children and are available to students and professionals at www.Psychotherapy
.net. New articles, interviews, blogs, therapy cartoons, and videos are published
monthly. For this chapter, see the following:
Carlson, J. (1997). Adlerian Therapy (Psychotherapy with the Experts Series)
Carlson, J. (2001). Adlerian Parent Consultation (Child Therapy with the
Experts Series)
Kottman, T. (2001). Adlerian Play Therapy (Child Therapy with the Experts
Series)
Two other videos that depict Adlerian therapy with a real client are available from
the American Psychological Association (http://www.apa.org/pubs/videos/index
.aspx). One shows an example of brief Adlerian therapy, and the other shows six ses-
sions of the working with the same client over time:
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128 C H A P T E R F I V E
Carlson, J. D. (2005). Adlerian Therapy (Systems of Psychotherapy series)
Carlson, J. D. (2006). Psychotherapy Over Time (Psychotherapy in Six Sessions
video series)
If your thinking is allied with the Adlerian approach, consider seeking training
in Individual Psychology or becoming a member of the North American Society
of Adlerian Psychology (NASAP). To obtain information on NASAP and a list of
Adlerian organizations and institutes, contact:
North American Society of Adlerian Psychology (NASAP)
www.alfredadler.org
The society publishes a newsletter and a quarterly journal and maintains a list of
institutes, training programs, and workshops in Adlerian psychology. The Journal of
Individual Psychology presents current scholarly and professional research. Columns
on counseling, education, and parent and family education are regular features.
Information about subscriptions is available by contacting the society.
If you are interested in pursuing training, postgraduate study, continuing
education, or a degree, contact NASAP for a list of Adlerian organizations and insti-
tutes. A few training institutes are listed here:
Adler School of Professional Psychology
www.adler.edu
Adlerian Training Institute, Inc.
www.adleriantraining.com
International Committee of Adlerian Summer Schools and Institutes
www.icassi.net
Recommended Supplementary Readings
Adlerian Therapy: Theory and Practice (Carlson, Watts,
& Maniacci, 2006) clearly presents a comprehensive
overview of Adlerian therapy in contemporary prac-
tice. There are chapters on the therapeutic relation-
ship, brief individual therapy, brief couples therapy,
group therapy, play therapy, and consultation. A list
of available Adlerian intervention videos is provided.
Alfred Adler Revisited (Carlson & Maniacci, 2012)
represents some of Adler’s most important writ-
ings placed into contemporary contexts by many of
today’s leading Adlerian scholars and practitioners.
Adlerian Counseling and Psychotherapy: A Practitioner’s
Approach (Sweeney, 2009) is one of the most compre-
hensive books written on the wide range of Adlerian
applications to therapy and wellness.
Early Recollections: Interpretative Method and Applica-
tion (Mosak & Di Pietro, 2006) is an extensive review
of the use of early recollections as a way to under-
stand an individual’s dynamics and behavioral style.
This book addresses the theory, research, and clini-
cal applications of early recollections.
The Key to Psychotherapy: Understanding the Self-created
Individual (Powers & Griffith, 2012a) is a useful source
of information for doing a lifestyle assessment. Sepa-
rate chapters deal with interview techniques, lifestyle
assessment, early recollections, the family constella-
tion, and methods of summarizing and interpreting
information.
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129
6Existential Therapy
1. Identify the major themes that
characterize existential philosophy
and therapy.
2. Compare the unique contributions
of some prominent existential
thinkers and therapists.
3. Examine the key concepts and
basic assumptions underlying
this approach, including self-
awareness, freedom and
responsibility, intimacy and
isolation, meaning in life, death
anxiety, and authenticity.
4. Identify the therapeutic goals
of existential therapy.
5. Understand the unique emphasis
placed on the therapeutic
relationship.
6. Describe the three phases of
existential counseling.
7. Understand the applications of
this approach to brief therapy.
8. Identify the applications of this
approach to group counseling.
9. Describe ways in which the
existential approach is and is
not well suited to multicultural
counseling.
10. Evaluate the contributions and
limitations of the existential
approach.
L e a r n i n g O b j e c t i v e s
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130 C H A P T E R S I X
VIKTOR FRANKL (1905–1997) was born
and educated in Vienna. He founded the
Youth Advisement Centers there in 1928
and directed them until 1938. From 1942
to 1945 Frankl was a prisoner in the Nazi
concentration camps at Auschwitz and
Dachau, where his parents, brother, wife,
and children died. He vividly remembered
his horrible experiences in these camps,
but he did not allow them to dampen his
love and enthusiasm for life. He traveled
all around the world, giving lectures in
Europe, Latin America, Southeast Asia,
and the United States.
Frankl received his MD in 1930 and his PhD
in philosophy in 1949, both from the University of
Vienna. He became an associate professor at the
University of Vienna and later was a distinguished
speaker at the United States International University
in San Diego. He was a visiting professor at Harvard,
Stanford, and Southern Methodist universities.
Frankl’s works have been translated into more than
20 languages, and his ideas continue to have a major
impact on the development of existential therapy. His
compelling book Man’s Search for Meaning (1963) has
been a best-seller around the world.
Although Frankl had begun to develop an existen-
tial approach to clinical practice before his grim years in
the Nazi death camps, his experiences there confirmed
his views. Frankl (1963) observed and personally expe-
rienced the truths expressed by existential philosophers
and writers who hold that we have choices in every
situation. Even in terrible circumstances, he believed,
we could preserve a vestige of spiritual freedom and
independence of mind. He learned experientially that
everything could be taken from a person except one
thing: “the last of human freedoms—to choose one’s
attitude in any given set of circumstances, to choose
one’s own way” (p. 104). Frankl believed that the
essence of being human lies in searching for meaning
and purpose. We can discover this meaning through
our actions and deeds, by experiencing a value (such
as love or achievements), and by suffering.
Frankl was deeply influenced by
Freud, but he disagreed with the rigid-
ity of Freud’s psychoanalytic system and
became a student of Alfred Adler. React-
ing against most of Freud’s deterministic
notions, Frankl developed his own the-
ory and practice of psychotherapy, which
emphasized the concepts of freedom,
responsibility, meaning, and the search
for values. He established his interna-
tional reputation as the founder of what
has been called “The Third School of
Viennese Psychoanalysis,” the other two
being Sigmund Freud’s psychoanalysis and Alfred
Adler’s Individual Psychology.
Frankl was a central figure in developing existen-
tial therapy in Europe and in bringing it to the United
States. He was fond of quoting Nietzsche: “He who
has a why to live for can bear with almost any how”
(as cited in Frankl, 1963, pp. 121, 164). Frankl con-
tended that those words could be the motto for all
psychotherapeutic practice. Another quotation from
Nietzsche seems to capture the essence of Frankl’s
own experience and writings: “That which does not
kill me, makes me stronger” (as cited in Frankl, 1963,
p. 130).
Frankl developed logotherapy, which means
“therapy through meaning.” Frankl’s philosophical
model sheds light on what it means to be fully alive.
The central themes running through his works are
life has meaning, under all circumstances; the central
motivation for living is the will to meaning; we have
the freedom to find meaning in all that we think; and
we must integrate body, mind, and spirit to be fully alive.
Frankl’s writings reflect the theme that the modern
person has the means to live, but often has no mean-
ing to live for.
I have selected Frankl as one of the key figures of
the existential approach because of the dramatic way
in which his theories were tested by the tragedies of
his life. His life was an illustration of his theory, for he
lived what his theory espouses.
Viktor Frankl
Im
ag
no
/V
ik
to
r F
ra
nk
l A
rc
hi
v
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E X I S T E n T I A l T H E R A P y 131
ROLLO MAY (1909–1994) first lived in
Ohio and then moved to Michigan as a
young child along with his five brothers
and a sister. He remembered his home
life as being unhappy, a situation that
contributed to his interest in psychology
and counseling. In his personal life, May
struggled with his own existential con-
cerns and the failure of two marriages.
May graduated from Oberlin Col-
lege in 1930 and then went to Greece as
a teacher. During his summers in Greece
he traveled to Vienna to study with Alfred
Adler. After receiving a degree in theology from
Union Theological Seminary, May decided that the
best way to reach out and help people was through
psychology instead of theology. He completed his
doctorate in clinical psychology at Columbia Univer-
sity and started a private practice in New York; he also
became a supervisory training analyst for the William
Alanson Institute.
While May was pursuing his doctoral program,
he came down with tuberculosis, which resulted in
a two-year stay in a sanitarium. During his recov-
ery period, May spent much time learning firsthand
about the nature of anxiety. He also spent time read-
ing, and he studied the works of Søren Kierkegaard,
which was the catalyst for May recognizing the exis-
tential dimensions of anxiety and resulted in him
writing The Meaning of Anxiety (1950). His popular
book Love and Will (1969) reflects his own personal
struggles with love and intimate relationships and
mirrors Western society’s questioning of its values
pertaining to sex and marriage.
The greatest personal influence on
Rollo May was the existential theologian
Paul Tillich (author of The Courage to Be,
1952), who became his mentor and a per-
sonal friend. The two spent much time
together discussing philosophical, reli-
gious, and psychological topics. May was
deeply influenced by the existential phi-
losophers, by the concepts of Freudian
psychology, and by many aspects of Alfred
Adler’s Individual Psychology. Most of
May’s writings reflect a concern with the
nature of human experience, such as rec-
ognizing and dealing with power, accepting freedom
and responsibility, and discovering one’s identity. He
draws from his rich knowledge based on the classics
and his existential perspective.
May’s writings have had a significant impact on
existentially oriented practitioners, and his writings
helped translate key existential concepts into psycho-
therapeutic practice in the United States and Europe.
May believed psychotherapy should be aimed at
helping people discover the meaning of their lives
and should be concerned with the problems of being
rather than with problem solving. It takes courage to
“be,” and our choices determine the kind of person we
become. Questions of being include learning to deal
with issues such as sex and intimacy, growing old, fac-
ing death, and taking action in the world. According
to May, the real challenge is for people to be able to
live in a world where they are alone and where they
will eventually have to face death. It is the task of
therapists to help individuals find ways to contribute
to the betterment of the society in which they live.
IRVIN YALOM (b. 1931) was born of
parents who immigrated from Russia
shortly after World War I. During his
early childhood, Yalom lived in the inner
city of Washington, D.C., in a poor neigh-
borhood. Life on the streets was perilous,
and Yalom took refuge indoors reading
novels and other works. Twice a week he
made the hazardous bicycle trek to the
library to stock up on reading supplies.
He found an alternative and satisfying
world in reading fiction, which was a
source of inspiration and wisdom to him.
Early in his life he decided that writing a
novel was the very finest thing a person
could do, and subsequently he has writ-
ten several teaching novels.
Irvin Yalom is Professor Emeritus
of Psychiatry at the Stanford Univer-
sity School of Medicine. A psychiatrist
and author, Yalom has been a major fig-
ure in the field of group psychotherapy
since publication in 1970 of his influen-
tial book The Theory and Practice of Group
Rollo May
H
ul
to
n
A
rc
hi
ve
/G
et
ty
Im
ag
es
Irvin Yalom
G
er
al
d
Co
re
y
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132 C H A P T E R S I X
Introduction
Existential therapy is more a way of thinking, or an attitude about psycho- LO1
therapy, than a particular style of practicing psychotherapy. It is neither an inde-
pendent or separate school of therapy, nor is it a clearly defined model with specific
techniques. Existential therapy can best be described as a philosophical approach that
influences a counselor’s therapeutic practice.
Existential psychotherapy is an attitude toward human suffering and has no
manual. It asks deep questions about the nature of the human being and the
nature of anxiety, despair, grief, loneliness, isolation, and anomie. It also deals
centrally with the questions of meaning, creativity, and love. (Yalom & Josselson,
2014, p. 265)
Existential therapy focuses on exploring themes such as mortality, meaning,
freedom, responsibility, anxiety, and aloneness as these relate to a person’s current
struggle. The goal of existential therapy is to assist clients in their exploration of
the existential “givens of life,” how these are sometimes ignored or denied, and how
addressing them can ultimately lead to a deeper, more reflective and meaningful
existence. Clients are invited to reflect on life, to recognize their range of alternatives,
and to decide among them. Existential therapy is grounded on the assumption that
we are free and therefore responsible for our choices and actions. We are the authors
Psychotherapy (1970/2005b), which has been trans-
lated into 12 languages and is currently in its fifth
edition. His pioneering work, Existential Psychotherapy,
written in 1980, is a classic and authoritative textbook
on existential therapy. A contemporary existential
therapist in the United States, Yalom acknowledges
the contributions of both European and American
psychologists and psychiatrists to the development
of existential thinking and practice. Drawing on his
clinical experience and on empirical research, phi-
losophy, and literature, Yalom developed an existen-
tial approach to psychotherapy that addresses four
“givens of existence,” or ultimate human concerns:
freedom and responsibility, existential isolation,
meaninglessness, and death. These existential themes
deal with the client’s existence, or being-in-the-world.
Yalom believes the vast majority of experienced ther-
apists, regardless of their theoretical orientation,
address these core existential themes. How we address
these existential themes greatly influences the design
and quality of our lives.
Psychotherapy has been endlessly intriguing for
Yalom, who has approached all of his patients with
a sense of wonderment at the stories they reveal. He
believes that a different therapy must be designed
for each client because each has a unique story. He
advocates using the here and now of the therapeu-
tic relationship to explore the client’s interpersonal
world, and believes the therapist must be transpar-
ent, especially regarding his or her experience of the
client. His basic philosophy is existential and inter-
personal, which he applies to both individual and
group therapy.
Irvin Yalom has authored many stories and
novels related to psychotherapy, including Love’s
Executioner (1987), When Nietzsche Wept (1992), Lying
on the Couch (1997), Momma and the Meaning of Life
(2000), and The Schopenhauer Cure (2005a). His 2008
nonfiction book, Staring at the Sun: Overcoming the
Terror of Death, is a treatise on the role of death
anxiety in psychotherapy, illustrating how death
and the meaning of life are foundational themes
associated with in-depth therapeutic work. Yalom’s
works, translated into more than 20 languages,
have been widely read by therapists and laypeople
alike.
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E X I S T E n T I A l T H E R A P y 133
of our lives, and we design the pathways we follow. This chapter addresses some of
the existential concepts and themes that have significant implications for the exis-
tentially oriented practitioner.
A basic existential premise is that we are not victims of circumstance because,
to a large extent, we are what we choose to be. Once clients begin the process of
recognizing the ways in which they have passively accepted circumstances and
surrendered control, they can start down a path of consciously shaping their own
lives. The first step in the therapeutic journey is for clients to accept responsibility.
As Yalom (2003) puts it, “Once individuals recognize their role in creating their
own life predicament, they also realize that they, and only they, have the power to
change that situation” (p. 141). The aim of existential therapy is to invite clients
to explore their values and beliefs and take action that grows out of this honest
appraisal of their life’s purpose. The therapist’s basic task is to encourage clients
to consider what they are most serious about so they can pursue a direction in life
(Deurzen, 2012).
Visit CengageBrain.com or watch the DVD for the video program on Chapter 6, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Historical Background in Philosophy and Existentialism
Many streams of thought contributed to the existential therapy movement
in the 1940s and 1950s, and it arose spontaneously in different parts of Europe
and among different schools of psychology and psychiatry. Many Europeans
found that their lives had been devastated by World War II, and they struggled
with existential issues including feelings of isolation, alienation, and meaning-
lessness. Early writers focused on the individual’s experience of being alone in the
world and facing the anxiety of this situation. The European existential perspec-
tive focused on human limitations and the tragic dimensions of life (Sharp &
Bugental, 2001).
The thinking of existential psychologists and psychiatrists was influenced by
a number of philosophers and writers during the 19th century. To understand
the philosophical underpinnings of modern existential psychotherapy, one must
have some awareness of the cultural, philosophical, and religious writings of Søren
Kierkegaard, Friedrich Nietzsche, Martin Heidegger, Jean-Paul Sartre, and Martin
Buber. These major figures of existentialism and existential phenomenology pro-
vided the basis for the formation of existential therapy. Ludwig Binswanger and
Medard Boss were also early existential psychoanalysts who contributed key ideas
to existential psychotherapy. Acknowledging the influence of these early philoso-
phers, Yalom found that each contributed significant themes that guided his own
thinking:
�� From Kierkegaard: creative anxiety, despair, fear and dread, guilt, and
nothingness
�� From Nietzsche: death, suicide, and will
LO2
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134 C H A P T E R S I X
�� From Heidegger: authentic being, caring, death, guilt, individual
responsibility, and isolation
�� From Sartre: meaninglessness, responsibility, and choice
�� From Buber: interpersonal relationships, I/Thou perspective in therapy,
and self-transcendence
Søren Kierkegaard (1813–1855) A Danish philosopher and Christian theol-
ogian, Kierkegaard was particularly concerned with angst—a Danish and German
word whose meaning lies between the English words dread and anxiety—and he
addressed the role of anxiety and uncertainty in life. Existential anxiety is associated
with making basic decisions about how we want to live, and it is not pathological.
Kierkegaard believed that anxiety is the school in which we are educated to be a self.
Without the experience of angst, we may go through life as sleepwalkers. But many
of us, especially in adolescence, are awakened into real life by a terrible uneasiness.
Life is one contingency after another, with no guarantees beyond the certainty of
death. This is by no means a comfortable state, but it is necessary to our becoming
human. Kierkegaard believed that “the sickness unto death” arises when we are not
true to ourselves. What is needed is the willingness to risk a leap of faith in making
choices. Becoming human is a project, and our task is not so much to discover who
we are as to create ourselves.
Friedrich Nietzsche (1844–1900) The German philosopher Nietzsche is the
iconoclastic counterpart to Kierkegaard, expressing a revolutionary approach to
the self, to ethics, and to society. Like Kierkegaard, he emphasized the importance
of subjectivity. Nietzsche set out to prove that the ancient definition of humans
as rational was entirely misleading. We are far more creatures of will than we are
impersonal intellects. But where Kierkegaard emphasized the “subjective truth”
of an intense concern with God, Nietzsche located values within the individual’s
“will to power.” We give up an honest acknowledgment of this source of value when
society invites us to rationalize powerlessness by advocating other worldly concerns.
If, like sheep, we acquiesce in “herd morality,” we will be nothing but mediocrities.
But if we release ourselves by giving free rein to our will to power, we will tap our
potentiality for creativity and originality. Kierkegaard and Nietzsche, with their
pioneering analyses of anxiety, depression, subjectivity, and the authentic self,
together are generally considered to be the originators of the existential perspective
(Sharp & Bugental, 2001).
Martin Heidegger (1889–1976) Heidegger’s phenomenological existentialism
reminds us that we exist “in the world” and should not try to think of ourselves
as beings apart from the world into which we are thrown. The way we fill our
everyday life with superficial conversation and routine shows that we often assume
we are going to live forever and can afford to waste day after day. Our moods and
feelings (including anxiety about death) are a way of understanding whether we are
living authentically or whether we are inauthentically constructing our life around
the expectations of others. When we translate this wisdom from vague feeling to
explicit awareness, we may develop a more positive resolve about how we want to
be. Phenomenological existentialism, as presented by Heidegger, provides a view of
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E X I S T E n T I A l T H E R A P y 135
human history that does not focus on past events but motivates individuals to look
forward to “authentic experiences” that are yet to come.
Martin Buber (1878–1965) Leaving Germany to live in the new state of Israel,
Buber took a less individualistic stand than most of the other existentialists. He said
that we humans live in a kind of betweenness; that is, there is never just an I, but
always an other. The I, the person who is the agent, changes depending on whether
the other is an it or a Thou. But sometimes we make the serious mistake of reducing
another person to the status of a mere object, in which case the relationship becomes
I/it. Although Buber recognizes that of necessity we must have many I/it interactions
(in everyday life), we are seriously limited if we live only in the world of the I/it. Buber
stresses the importance of presence, which has three functions: (1) it enables true I/
Thou relationships; (2) it allows for meaning to exist in a situation; and (3) it enables
an individual to be responsible in the here and now (Gould, 1993). In a famous
dialogue with Carl Rogers, Buber argued that the therapist and the client could
never be on the same footing because the latter comes to the former for help. When
the relationship is fully mutual, we have become “dialogic,” a fully human condition.
Ludwig Binswanger (1881–1966) An existential analyst, Binswanger proposed
a holistic model of self that addresses the relationship between the person and his
or her environment. He used a phenomenological approach to explore significant
features of the self, including choice, freedom, and caring. He based his existential
approach largely on the ideas of Heidegger and accepted Heidegger’s notion that
we are “thrown into the world.” However, this “thrown-ness” does not release us
from the responsibility of our choices and for planning for the future (Gould,
1993). existential analysis (Daseinanalysis) emphasizes the subjective and spiritual
dimensions of human existence. Binswanger (1975) contended that crises in therapy
were typically major choice points for the client. Although he originally looked to
psychoanalytic theory to shed light on psychosis, he moved toward an existential
view of his patients. This perspective enabled him to understand the worldview and
immediate experience of his patients, as well as the meaning of their behavior, as
opposed to superimposing his view as a therapist on their experience and behavior.
Medard Boss (1903–1991) Both Binswanger and Boss were early existential
psychoanalysts and significant figures in the development of existential
psychotherapy. They talked of dasein, or being-in-the-world, which pertains to our
ability to reflect on life events and attribute meaning to these events. They believed
the therapist must enter the client’s subjective world without presuppositions that
would get in the way of this experiential understanding. Both Binswanger and Boss
were significantly influenced by Heidegger’s seminal work, Being and Time (1962),
which provided a broad basis for understanding the individual (May, 1958). Boss
was deeply influenced by Freudian psychoanalysis, but even more so by Heidegger.
Boss’s major professional interest was applying Heidegger’s philosophical notions
to therapeutic practice, and he was especially concerned with integrating Freud’s
methods with Heidegger’s concepts, as described in his book Daseinanalysis and
Psychoanalysis (1963).
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136 C H A P T E R S I X
Jean-Paul Sartre (1905–1980) A philosopher and novelist, Sartre was convinced,
in part by his years in the French Resistance in World War II, that humans are
even more free than earlier existentialists had believed. The existence of a space—
nothingness—between the whole of our past and the now frees us to choose what we
will. Our values are what we choose. The failure to acknowledge our freedom and
choices results in emotional problems. This freedom is hard to face, so we tend to
invent an excuse by saying, “I can’t change now because of my past conditioning.”
Sartre called excuses “bad faith.” No matter what we have been, we can make choices
now and become something quite different. We are condemned to be free. To choose
is to become committed; this is the responsibility that is the other side of freedom.
Sartre’s view was that at every moment, by our actions, we are choosing who we are
being. Our existence is never fixed or finished. Every one of our actions represents a
fresh choice. When we attempt to pin down who we are, we engage in self-deception
(Russell, 2007).
Key Figures in Contemporary Existential Psychotherapy
Viktor Frankl, Rollo May, and Irvin Yalom (featured at the beginning of the chap-
ter) created their existential approaches to psychotherapy from their strong back-
grounds in both existential and humanistic psychology. James Bugental has also
made major contributions to the development of existential therapy in the United
States, and Emmy van Deurzen continues to influence the practice of existential
therapy in Great Britain.
James Bugental (1915–2008) James Bugental (1987) wrote about life-changing
psychotherapy, which is the effort to help clients examine how they have answered
life’s existential questions and to invite them to revise their answers so they can
live more authentically. Bugental coined the term “existential-humanistic”
psychotherapy, and he was a leading spokesman for this approach. His philosophical
and therapeutic approach included a curiosity and focus that moved him away
from the traditional therapeutic milieu of labeling and diagnosing clients. His
work emphasized the cultivation of both client and therapist presence. He developed
interventions to assist the client in deepening inner exploration, or searching. The
therapist’s primary task involved helping clients make new discoveries about
themselves in the living moment, as opposed to merely talking about themselves.
Central to Bugental’s approach is his view of resistance, which from an existen-
tial-humanistic perspective is not resistance to therapy per se but rather to being fully
present both during the therapy hour and in life. Resistance is seen as part of the
self-and-world construct—how a person understands his or her being and relationship
to the world at large. Forms of resistance include intellectualizing, being argumen-
tative, always seeking to please, and any other life-limiting pattern. As resistance
emerges in the therapy sessions, the therapist repeatedly notes, or “tags,” the resis-
tance so the client increases his or her awareness and ultimately has an increased
range of choices.
Bugental’s theory and practice emphasized the distinction between therapeu-
tic process and content. He became known for being a masterful teacher and psy-
chotherapist, primarily because he lived his work. He was an existentialist at heart,
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E X I S T E n T I A l T H E R A P y 137
which made him a great model and mentor, not only for clients but also for students
and professionals. In his workshops, he developed many exercises to help thera-
pists refine and practice their skills. He frequently brought his interventions to life
with live demonstrations, which emphasized therapeutic work taking place in the
moment, impromptu here-and-now dialogue, and exploring in the context of self as
client or therapist. Bugental’s (1987) classic text, The Art of the Psychotherapist, is widely
recognized for deconstructing the therapy process and moving beyond theory and
generalizations to show what actually occurs moment-to-moment in the therapeu-
tic encounter. Psychotherapy Isn’t What You Think (Bugental, 1999) is the last book he
wrote before he died in 2008, at the age of 93.
British Contribution to Existential Therapy Emmy van Deurzen, a key contri-
butor to British existential psychology, is a philosopher, psychotherapist, and
counseling psychologist. Deurzen has earned a worldwide reputation in existential
psychotherapy through her many books and her role in teaching and training.
Deurzen (2012) states that existential therapy is not designed to “cure” people of
illness in the tradition of the medical model because people are not sick but are
“sick of life or clumsy at living” (p. 30). Deurzen’s (2014) psychotherapy practice has
taught her that individuals have incredible resilience and intelligence in overcoming
their problems once they commit themselves to a self-searching process. Her
therapy clients find meaning in their past hardships rather than experiencing these
difficulties as defining them in old patterns. Her clients are able to recognize the
contradictions and paradoxes of life and to face their troubles and solve dilemmas.
They also discover what is most important in life.
Deurzen is the cofounder of the New School of Psychotherapy and Counselling,
which is developing academic and training programs. In the past decades the exis-
tential approach has spread rapidly in Britain and is now an alternative to tradi-
tional methods (Deurzen, 2002, 2012). For a description of the historical context
and development of existential therapy in Britain, see Deurzen (2002), Deurzen and
Adams (2011), and Cooper (2003); for an excellent overview of the theory and prac-
tice of existential therapy, see Deurzen (2012) and Schneider and Krug (2010). For
information on the New School in Britain, see the Other Resources section at the
end of this chapter.
Key Concepts
View of Human Nature
The crucial significance of the existential movement is that it reacts against
the tendency to identify therapy with a set of techniques. Instead, it bases thera-
peutic practice on an understanding of what it means to be human. The existential
movement stands for respect for the person, for exploring new aspects of human
behavior, and for divergent methods of understanding people. It uses numerous
approaches to therapy based on its assumptions about human nature.
The existential tradition seeks a balance between recognizing the limits
and tragic dimensions of human existence on one hand and the possibilities and
LO3
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138 C H A P T E R S I X
opportunities of human life on the other hand. It grew out of a desire to help people
engage the dilemmas of contemporary life, such as isolation, alienation, and mean-
inglessness. The current focus of the existential approach is on the individual’s
experience of being in the world alone and facing the anxiety of this isolation. “No
relationship can eliminate existential isolation, but aloneness can be shared in such
a way that love compensates for its pain” (Yalom & Josselson, 2014, p. 281).
The existential view of human nature is captured, in part, by the notion that the
significance of our existence is never fixed once and for all; rather, we continually re-
create ourselves through our projects. Humans are in a constant state of transition,
emerging, evolving, and becoming in response to the tensions, contradictions, and
conflicts in our lives. Being a person implies that we are discovering and making
sense of our existence. We continually question ourselves, others, and the world.
Although the specific questions we raise vary in accordance with our developmen-
tal stage in life, the fundamental themes do not vary. We pose the same questions
philosophers have pondered throughout Western history: “Who am I?” “What can I
know?” “What ought I to do?” “What can I hope for?” “Where am I going?”
The basic dimensions of the human condition, according to the existential
approach, include (1) the capacity for self-awareness; (2) freedom and responsibility;
(3) creating one’s identity and establishing meaningful relationships with others;
(4) the search for meaning, purpose, values, and goals; (5) anxiety as a condition of
living; and (6) awareness of death and nonbeing. I develop these propositions in the
following sections by summarizing themes that emerge in the writings of existential
philosophers and psychotherapists, and I also discuss the implications for counsel-
ing practice of each of these propositions.
Proposition 1: The Capacity for Self-Awareness
Freedom, choice, and responsibility constitute the foundation of self-awareness. The
greater our awareness, the greater our possibilities for freedom (see Proposition 2). We
increase our capacity to live fully as we expand our awareness in the following areas:
�� We are finite and do not have unlimited time to do what we want
in life.
�� We have the potential to take action or not to act; inaction is a decision.
�� We choose our actions, and therefore we can partially create our own
destiny.
�� Meaning is the product of discovering how we are “thrown” or situated
in the world and then, through commitment, living creatively.
�� As we increase our awareness of the choices available to us, we also
increase our sense of responsibility for the consequences of these choices.
�� We are subject to loneliness, meaninglessness, emptiness, guilt,
and isolation.
�� We are basically alone, yet we have an opportunity to relate to other
beings.
We can choose either to expand or to restrict our consciousness. Because self-
awareness is at the root of most other human capacities, the decision to expand it
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E X I S T E n T I A l T H E R A P y 139
is fundamental to human growth. Here are some areas of emerging awareness that
individuals may experience in the counseling process:
�� They see how they are trading the security of dependence for the anxiet-
ies that accompany choosing for themselves.
�� They begin to see that their identity is anchored in someone else’s defi-
nition of them; that is, they are seeking approval and confirmation of
their being in others instead of looking to themselves for affirmation.
�� They learn that in many ways they are keeping themselves prisoner by
some of their past decisions, and they realize that they can make new
decisions.
�� They learn that although they cannot change certain events in their
lives they can change the way they view and react to these events.
�� They learn that they are not condemned to a future similar to the past,
for they can learn from their past and thereby reshape their future.
�� They realize that they are so preoccupied with suffering, death, and
dying that they are not appreciating living.
�� They are able to accept their limitations yet still feel worthwhile, for
they understand that they do not need to be perfect to feel worthy.
�� They come to realize that they are failing to live in the present moment
because of preoccupation with the past, planning for the future, or try-
ing to do too many things at once.
Increasing self-awareness—which includes awareness of alternatives, motiva-
tions, factors influencing the person, and personal goals—is an aim of all counsel-
ing. Clients need to learn that a price must be paid for increased awareness. As we
become more aware, it is more difficult to “go home again.” Ignorance of our condi-
tion may have brought contentment along with a feeling of partial deadness, but as
we open the doors in our world, we can expect more turmoil as well as the potential
for more fulfillment.
Proposition 2: Freedom and Responsibility
A characteristic existential theme is that people are free to choose among alterna-
tives and therefore play a large role in shaping their own destiny. Schneider and
Krug (2010) write that existential therapy embraces three values: (1) the freedom to
become within the context of natural and self-imposed limitations; (2) the capacity
to reflect on the meaning of our choices; and (3) the capacity to act on the choices
we make. Although we do not choose the circumstances into which we are born,
we create our own destiny by the choices we make. Sartre claims we are constantly
confronted with the choice of what kind of person we are becoming, and to exist
is never to be finished with this kind of choosing. Living an authentic existence
requires that we assume responsibility for our choices (Ruben & Lichtanski, 2015).
A central existential concept is that although we long for freedom we often try
to escape from our freedom by defining ourselves as a fixed or static entity (Russell,
2007). Jean-Paul Sartre (1971) refers to this as the inauthenticity of not accepting
personal responsibility. We can then avoid choosing and instead make excuses such
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140 C H A P T E R S I X
as these: “Since that’s the way I’m made, I couldn’t help what I did” or “Naturally
I’m this way, because I grew up in a dysfunctional family.” An inauthentic mode of
existence consists of lacking awareness of personal responsibility for our lives and
passively assuming that our existence is largely controlled by external forces.
Freedom implies that we are responsible for our lives, for our actions, and for
our failures to take action. From Sartre’s perspective, people are condemned to free-
dom. He calls for a commitment to choosing for ourselves. existential guilt is being
aware of having evaded a commitment, or having chosen not to choose. This guilt is
a condition that grows out of a sense of incompleteness, or a realization that we are
not what we might have become. Guilt may be a sign that we have failed to rise to the
challenge of our anxiety and that we have tried to evade it by not doing what we know
is possible for us to do (Deurzen, 2012). This condition is not viewed as neurotic,
nor is it seen as a symptom that needs to be cured. Existential guilt can be a power-
ful source of motivation toward transformation and living authentically (Ruben &
Lichtanski, 2015). The existential therapist explores this guilt to see what clients can
learn about the ways in which they are living their life. This guilt also results from
allowing others to define us or to make our choices for us. Sartre said, “We are our
choices.” authenticity implies that we are living by being true to our own evaluation
of what is a valuable existence for ourselves; it is the courage to be who we are. One of
the aims of existential therapy is to help people face up to the difficulties of life with
courage rather than avoiding life’s struggles (Deurzen & Adams, 2011).
For existentialists, then, being free and being human are identical. Freedom and
responsibility go hand in hand. We are the authors of our lives in the sense that we
create our destiny, our life situation, and our problems (Russell, 1978). Assuming
responsibility is a basic condition for change. Clients who refuse to accept responsi-
bility by persistently blaming others for their problems are not likely to profit from
therapy.
Frankl (1978) also links freedom with responsibility. He suggested that the
Statue of Liberty on the East Coast should be balanced with a Statue of Responsibil-
ity on the West Coast. His basic premise is that freedom is bound by certain limita-
tions. We are not free from conditions, but we are free to take a stand against these
restrictions. Ultimately, these conditions are subject to our decisions, which means
we are responsible.
The therapist assists clients in discovering how they are avoiding freedom and
encourages them to learn to risk using it. Not to do so is to cripple clients and make
them dependent on the therapist. Therapists have the task of teaching clients that
they can explicitly accept that they have choices, even though they may have devoted
most of their life to evading them. Those who are in therapy often have mixed feel-
ings when it comes to choice. As Russell (2007) puts it: “We resent it when we don’t
have choices, but we get anxious when we do! Existentialism is all about broadening
the vision of our choices” (p. 111).
People often seek psychotherapy because they feel that they have lost control of
how they are living. They may look to the counselor to direct them, give them advice,
or produce magical cures. They may also need to be heard and understood. Two
central tasks of the therapist are inviting clients to recognize how they have allowed
others to decide for them and encouraging them to take steps toward choosing for
themselves. In inviting clients to explore other ways of being that are more fulfilling
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E X I S T E n T I A l T H E R A P y 141
than their present restricted existence, some existential counselors ask, “Although
you have lived in a certain pattern, now that you recognize the price of some of your
ways, are you willing to consider creating new patterns?” Others may have a vested
interest in keeping the client in an old pattern, so the initiative for changing it will
have to come from the client.
Cultural factors need to be taken into account in assisting clients in the process
of examining their choices. A person who is struggling with feeling limited by her
family situation can be invited to look at her part in this process and values that are
a part of her culture. For example, Meta, a Norwegian American, is working to attain
a professional identity as a social worker, but her family thinks she is being selfish
and neglecting her primary duties. The family is likely to exert pressure on her to
give up her personal interests in favor of what they feel is best for the welfare of the
entire family. Meta may feel trapped in the situation and see no way out unless she
rejects what her family wants. In cases such as this, it is useful to explore the client’s
underlying values and to help her determine whether her values are working for her
and for her family. Clients such as Meta have the challenge of weighing values and
balancing behaviors between two cultures. Ultimately, Meta must decide in what
ways she might change her situation, and she needs to assess values based on her
culture. The existential therapist will invite Meta to begin to explore what she can do
and to realize that she can be authentic in spite of pressures on her by her situation.
According to Vontress (2013), we can be authentic in any society, whether we are a
part of an individualistic or collectivistic society.
It is essential to respect the purpose that people have in mind when they initiate
therapy. If we pay careful attention to what our clients tell us about what they want,
we can operate within an existential framework. We can encourage individuals to
weigh the alternatives and to explore the consequences of what they are doing with
their lives. Although oppressive forces may be severely limiting the quality of their
lives, we can help people see that they are not solely the victims of circumstances
beyond their control. Even though we sometimes cannot control things that happen
to us, we have complete control over how we choose to perceive and handle them.
Although our freedom to act is limited by external reality, our freedom to be relates
to our internal reality. At the same time that people are learning how to change
their external environment, they can be challenged to look within themselves to rec-
ognize their own contributions to their problems. Through the therapy experience,
clients may be able to discover new courses of action that will lead to a change in
their situation.
Proposition 3: Striving for Identity and Relationship to Others
People are concerned about preserving their uniqueness and centeredness, yet at
the same time they have an interest in going outside of themselves to relate to
other beings and to nature. Each of us would like to discover a self or, to put it
more authentically, to create our personal identity. This is not an automatic pro-
cess, and creating an identity takes courage. As relational beings, we also strive for
connectedness with others. Many existential writers discuss loneliness, uprooted-
ness, and alienation, which can be seen as the failure to develop ties with others and
with nature.
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142 C H A P T E R S I X
The trouble with so many of us is that we have sought directions, answers, val-
ues, and beliefs from the important people in our world. Rather than trusting our-
selves to search within and find our own answers to the conflicts in our life, we sell
out by becoming what others expect of us. Our being becomes rooted in their expec-
tations, and we become strangers to ourselves.
The Courage to Be Paul Tillich (1886–1965), a leading Protestant theologian of
the 20th century, believed awareness of our finite nature gives us an appreciation of
ultimate concerns. It takes courage to discover the true “ground of our being” and to
use its power to transcend those aspects of nonbeing that would destroy us (Tillich,
1952). Courage entails the will to move forward in spite of anxiety-producing
situations, such as facing our death (May, 1975). We struggle to discover, to create,
and to maintain the core deep within our being. One of the greatest fears of clients
is that they will discover that there is no core, no self, no substance, and that they are
merely reflections of everyone’s expectations of them. A client may say, “My fear is
that I’ll discover I’m nobody, that there really is nothing to me. I’ll find out that I’m
an empty shell, hollow inside, and nothing will exist if I shed my masks.” If clients
demonstrate the courage to confront these fears, they might well leave therapy with
an increased tolerance for the uncertainty of life. By assisting clients in facing the
fear that their lives or selves are empty and meaningless, therapists can help clients
to create a self that has meaning and substance that they have chosen.
Existential therapists may begin by asking their clients to allow themselves to
intensify the feeling that they are nothing more than the sum of others’ expectations
and that they are merely the introjects of parents and parent substitutes. How do
they feel now? Are they condemned to stay this way forever? Is there a way out? Can
they create a self if they find that they are without one? Where can they begin? Once
clients have demonstrated the courage to recognize this fear, to put it into words
and share it, it does not seem so overwhelming. I find that it is best to begin work by
inviting clients to accept the ways in which they have lived outside themselves and to
explore ways in which they are out of contact with themselves.
The Experience of Aloneness The existentialists postulate that part of the
human condition is the experience of aloneness. But they add that we can derive
strength from the experience of looking to ourselves and sensing our separation.
The sense of isolation comes when we recognize that we cannot depend on anyone
else for our own confirmation; that is, we alone must give a sense of meaning to life,
and we alone must decide how we will live. If we are unable to tolerate ourselves
when we are alone, how can we expect anyone else to be enriched by our company?
Before we can have any solid relationship with another, we must have a relationship
with ourselves. We are challenged to learn to listen to ourselves. We have to be able
to stand alone before we can truly stand beside another.
The Experience of Relatedness We humans depend on relationships with others.
We want to be significant in another’s world, and we want to feel that another’s
presence is important in our world. When we are able to stand alone and tap into
our own strength, our relationships with others are based on our fulfillment, not
our deprivation. If we feel personally deprived, however, we can expect little but a
clinging and symbiotic relationship with someone else.
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E X I S T E n T I A l T H E R A P y 143
Perhaps one of the functions of therapy is to help clients distinguish between
a neurotically dependent attachment to another and a life-affirming relationship
in which both persons are enhanced. The therapist can challenge clients to exam-
ine what they get from their relationships, how they avoid intimate contact, how
they prevent themselves from having equal relationships, and how they might create
therapeutic, healthy, and mature human relationships. Existential therapists speak
of intersubjectivity, which is the fact of our interrelatedness with others and the
need for us to struggle with this in a creative way.
Struggling With Our Identity Because of our fear of dealing with our aloneness,
Farha (1994) points out that some of us get caught up in ritualistic behavior patterns
that cement us to an image or identity we acquired in early childhood. We become
trapped in a doing mode to avoid the experience of being. Part of the therapeutic
journey consists of the therapist challenging clients to begin to examine the ways
in which they have lost touch with their identity, especially by letting others design
their life for them. The therapy process itself is often frightening for clients when
they realize that they have surrendered their freedom to others and that in the
therapy relationship they will have to assume their freedom again. By refusing to
give easy solutions or answers, existential therapists confront clients with the reality
that they alone must find their own answers.
Proposition 4: The Search for Meaning
A distinctly human characteristic is the struggle for a sense of significance and
purpose in life. In my experience the underlying conflicts that bring people into
counseling and therapy are centered in these existential questions: “Why am I here?”
“What do I want from life?” “What gives my life purpose?” “Where is the source of
meaning for me in life?”
Existential therapy can provide the conceptual framework for helping clients
challenge the meaning in their lives. Questions that the therapist might ask are,
“Do you like the direction of your life?” “Are you pleased with what you now are and
what you are becoming?” “If you are confused about who you are and what you want
for yourself, what are you doing to get some clarity?”
The Problem of Discarding Old Values One of the problems in therapy is
that clients may discard traditional (and imposed) values without creating other,
suitable ones to replace them. What does the therapist do when clients no longer
cling to values that they never really challenged or internalized and now experience
a vacuum? Clients may report that they feel like a boat without a rudder. They
seek new guidelines and values that are appropriate for the newly discovered facets
of themselves, and yet for a time they are without them. One of the tasks of the
therapeutic process is to help clients create a value system based on a way of living
that is consistent with their way of being.
The therapist’s job is to trust in the capacity of clients to eventually create an
internally derived value system that provides the foundation for a meaningful life.
They will no doubt flounder for a time and experience anxiety as a result of the
absence of clear-cut values. The therapist’s trust is important in helping clients trust
their own capacity to create a new source of values.
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144 C H A P T E R S I X
Meaninglessness According to Frankl (1963), the central human concern is to
discover meaning that will give one’s life direction. Frankl’s life experiences and his
clinical work led him to the conclusion that a lack of meaning is the major source
of existential stress and anxiety in modern times. He views existential neurosis as
the experience of meaninglessness. When the world we live in seems meaningless,
we may wonder whether it is worth it to continue struggling or even living. Faced
with the prospect of our mortality, we might ask, “Is there any point to what I do
now, since I will eventually die? Will what I do be forgotten when I am gone? Given
the fact of mortality, why should I busy myself with anything?” A man in one of
my groups captured precisely the idea of personal significance when he said, “I feel
like another page in a book that has been turned quickly, and nobody bothered to
read the page.” Frankl believes that such a feeling of meaninglessness is the major
existential neurosis of modern life.
Meaninglessness in life can lead to emptiness and hollowness, or a condition
that Frankl calls the existential vacuum. This condition is often experienced
when people do not busy themselves with routine or with work. Because there is
no preordained design for living, people are faced with the task of creating their
own meaning. At times people who feel trapped by the emptiness of life withdraw
from the struggle of creating a life with purpose. Experiencing meaninglessness and
establishing values that are part of a meaningful life are issues that become the heart
of counseling.
Creating New Meaning Logotherapy is designed to help clients find meaning
in life. The therapist’s function is not to tell clients what their particular meaning
in life should be but to point out that they can create meaning even in suffering
(Frankl, 1978). This view holds that human suffering (the tragic and negative
aspects of life) can be turned into human achievement by the stand an individual
takes when faced with it. Frankl also contends that people who confront pain, guilt,
despair, and death can effectively deal with their despair and thus triumph.
Yet meaning is not something that we can directly search for and obtain. Para-
doxically, the more rationally we seek it, the more likely we are to miss it. Meaning
is created out of an individual’s engagement with what is valued, and this commit-
ment provides the purpose that makes life worthwhile (Deurzen, 2012). I like the
way Vontress (2013) captures the idea that meaning in life is an ongoing process we
struggle with throughout our life: “What provides meaning one day may not pro-
vide meaning the next, and what has been meaningful to a person throughout life
may be meaningless when a person is on his or her deathbed” (p. 147).
Proposition 5: Anxiety as a Condition of Living
Anxiety arises from one’s personal strivings to survive and to maintain and assert
one’s being, and the feelings anxiety generates are an inevitable aspect of the human
condition. existential anxiety is the unavoidable result of being confronted with
the “givens of existence”—death, freedom, choice, isolation, and meaninglessness
(Vontress, 2013; Yalom, 1980; Yalom & Josselson, 2014). Existential anxiety arises
as we recognize the realities of our mortality, our confrontation with pain and suf-
fering, our need to struggle for survival, and our basic fallibility. We experience this
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E X I S T E n T I A l T H E R A P y 145
anxiety as we become increasingly aware of our freedom and the consequences of
accepting or rejecting that freedom. In fact, when we make a decision that involves
reconstruction of our life, the accompanying anxiety can be a signal that we are
ready for personal change and can be a stimulus for growth. If we learn to listen to
the subtle messages of anxiety, we can dare to take the steps necessary to change the
direction of our lives.
Existential therapists differentiate between normal and neurotic anxiety, and
they see anxiety as a potential source of growth. normal anxiety is an appropri-
ate response to an event being faced. Accepting freedom and the responsibility for
making decisions and life choices, searching for meaning, and facing mortality can
be frightening. This kind of anxiety does not have to be repressed, and it can be a
powerful motivational force toward change and growth (Ruben & Lichtanski, 2015).
From the existential viewpoint, normal anxiety is an invitation to freedom. “Anxiety
is a teacher, not an obstacle or something to be removed or avoided” (Deurzen &
Adams, 2011, p. 24).
Failure to move through anxiety results in neurotic anxiety, which is anxiety
about concrete things that is out of proportion to the situation. Neurotic anxiety is
typically out of awareness, and it tends to immobilize the person. Being psychologi-
cally healthy entails living with as little neurotic anxiety as possible, while accepting
and struggling with the unavoidable existential anxiety that is a part of living.
Many people who seek counseling want solutions that will enable them to elimi-
nate anxiety. Creating the illusion that there is security in life may help us cope with
the unknown, yet we know on some level that we are deceiving ourselves. Deurzen
(2012) believes that existential anxiety is part of living with awareness and being
fully alive. In fact, the courage to live fully entails accepting the reality of death and
the anxiety associated with uncertainty. Facing existential anxiety involves viewing
life as an adventure rather than hiding behind imagined securities that seem to offer
protection. Opening up to new life means opening up to anxiety. We pay a steep
price when we short-circuit anxiety.
The existential therapist can help clients recognize that learning how to tolerate
ambiguity and uncertainty and how to live without props can be a necessary phase
in the journey from dependence to autonomy. The therapist and client can explore
the possibility that although breaking away from crippling patterns and building
new ways of living will be fraught with anxiety for a while, anxiety will diminish as
the client experiences more satisfaction with newer ways of being. When a client
becomes more self-confident, the anxiety that results from an expectation of catas-
trophe is likely to decrease.
Proposition 6: Awareness of Death and Nonbeing
The existentialist does not view death negatively but holds that awareness of death
as a basic human condition gives significance to living. A distinguishing human
characteristic is the ability to grasp the reality of the future and the inevitability
of death. It is necessary to think about death if we are to think significantly about
life. Death should not be considered a threat; death provides the motivation for us
to take advantage of appreciating the present moment. Instead of being frozen by
the fear of death, reflecting on the reality of death can teach us how to live fully.
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146 C H A P T E R S I X
Deurzen and Adams (2011) write: “Life is a taskmaster, while death is a master
teacher” (p. 105). If we defend ourselves against the reality of our eventual death, life
becomes insipid and meaningless. But if we realize that we are mortal, we know that
we do not have an eternity to complete our projects and that the present is crucial.
Our awareness of death is the source of zest for life and creativity. Death and life are
interdependent, and though physical death destroys us, the idea of death saves us
(Yalom, 1980, 2003).
Yalom (2008) recommends that therapists talk directly to clients about the
reality of death. He believes the fear of death percolates beneath the surface and
haunts us throughout life. Death is a visitor in the therapeutic process, and Yalom
believes that ignoring its presence sends the message that death is too overwhelm-
ing to explore. Confronting this fear can be the factor that helps us transform an
inauthentic mode of living into a more authentic one. Accepting the reality of our
personal death can result in a major shift in the way we live in the world (Yalom &
Josselson, 2014). We can turn our fear of death into a positive force when we accept
the reality of our mortality. In Staring at the Sun: Overcoming the Terror of Death, Yalom
(2008) develops the idea that confronting death enables us to live in a more compas-
sionate way.
One focus in existential therapy is on exploring the degree to which clients
are doing the things they value. Without being morbidly preoccupied by the ever-
present threat of nonbeing, clients can develop a healthy awareness of death as a way
to evaluate how well they are living and what changes they want to make in their
lives. Those who fear death also fear life. When we emotionally accept the reality of
our eventual death, we realize more clearly that our actions do count, that we do
have choices, and that we must accept the ultimate responsibility for how well we
are living (Corey & Corey, 2014).
The Therapeutic Process
Therapeutic Goals
Existential therapy is best considered as an invitation to clients to recognize
the ways in which they are not living fully authentic lives and to make choices that
will lead to their becoming what they are capable of being. An aim of therapy is to
assist clients in moving toward authenticity and learning to recognize when they are
deceiving themselves (Deurzen, 2012). The existential orientation holds that there
is no escape from freedom as we will always be held responsible. We can relinquish
our freedom, however, which is the ultimate inauthenticity. Existential therapy
aims at helping clients face anxiety and engage in action that is based on the authen-
tic purpose of creating a worthy existence. Authenticity involves claiming author-
ship—taking responsibility for our actions and the way we are living (Deurzen
& Adams, 2011).
May (1981) contends that people come to therapy with the self-serving illusion
that they are inwardly enslaved and that someone else (the therapist) can free them.
Existential therapists are mainly concerned about helping people to reclaim and
reown their lives. The task of existential therapy is to teach clients to listen to what
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E X I S T E n T I A l T H E R A P y 147
they already know about themselves, even though they may not be attending to what
they know. Schneider and Krug (2010) identify four essential aims of existential-
humanistic therapy: (1) to help clients become more present to both themselves and
others; (2) to assist clients in identifying ways they block themselves from fuller pres-
ence; (3) to challenge clients to assume responsibility for designing their present
lives; and (4) to encourage clients to choose more expanded ways of being in their
daily lives.
Increased awareness is the central goal of existential therapy, which allows
clients to discover that alternative possibilities exist where none were recognized
before. Clients come to realize that they are able to make changes in their way of
being in the world.
Therapist’s Function and Role
Existential therapists are primarily concerned with understanding the subjective
world of clients to help them come to new understandings and options. Existen-
tial therapists are especially concerned about clients avoiding responsibility; they
consistently invite clients to accept personal responsibility. When clients complain
about the predicaments they are in and blame others, the therapist is likely to ask
them how they contributed to their situation.
Therapists with an existential orientation usually deal with people who have
what could be called a restricted existence. These clients have a limited awareness
of themselves and are often vague about the nature of their problems. They may see
few, if any, options for dealing with life situations, and they tend to feel trapped,
helpless, and stuck. One of the therapist’s functions is to assist clients in seeing
the ways in which they constrict their awareness and the cost of such constrictions
(Bugental, 1997). The therapist may hold up a mirror, so to speak, so that clients can
gradually engage in self-confrontation. In this way clients can see how they became
the way they are and how they might enlarge the way they live. Once clients are aware
of factors in their past and of stifling modes of their present existence, they can
begin to accept responsibility for changing their future.
Existential practitioners may make use of techniques that originate from diverse
theoretical orientations, yet no set of techniques is considered essential. The thera-
peutic journey is creative and uncertain and different for each client. Russell (2007)
captures this notion well when he writes: “There is no one right way to do therapy,
and certainly no rigid doctrine for existentially rooted techniques. What is crucial is
that you create your own authentic way of being attuned to your clients” (p. 123).
Existential therapists encourage experimentation not only within the therapy office
but also outside of the therapy setting, based on the belief that life outside therapy is
what counts. Practitioners often ask clients to reflect on or write about problematic
events they encounter in daily life (Schneider, 2011).
Client’s Experience in Therapy
Clients in existential therapy are clearly encouraged to assume responsibility for
how they are currently choosing to be in their world. Effective therapy does not stop
with this awareness itself, for the therapist encourages clients to take action on the
basis of the insights they develop through the therapeutic process. Experimentation
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148 C H A P T E R S I X
with new ways of behaving in the outside world is necessary if clients are to change.
Further, clients must be active in the therapeutic process, for during the sessions
they must decide what fears, guilt feelings, and anxieties they will explore.
Merely deciding to enter psychotherapy is itself a frightening prospect for most
people. The experience of opening the doors to oneself can be frightening, excit-
ing, joyful, depressing, or a combination of all of these. As clients wedge open the
closed doors, they also begin to loosen the deterministic shackles that have kept
them psychologically bound. Gradually, they become aware of what they have been
and who they are now, and they are better able to decide what kind of future they
want. Through the process of their therapy, individuals can explore alternatives for
making their visions real.
When clients plead helplessness and attempt to convince themselves that they
are powerless, May (1981) reminds them that their journey toward freedom began
by putting one foot in front of the other to get to his office. As narrow as their range
of freedom may be, individuals can begin building and augmenting that range by
taking small steps. The therapeutic journey that opens up new horizons is poetically
described by Deurzen (2010):
Embarking on our existential journey requires us to be prepared to be touched
and shaken by what we find on the way and to not be afraid to discover our own
limitations and weaknesses, uncertainties and doubts. It is only with such an atti-
tude of openness and wonder that we can encounter the impenetrable everyday
mysteries, which take us beyond our own preoccupations and sorrows and which
by confronting us with death, make us rediscover life. (p. 5)
Another aspect of the experience of being a client in existential therapy is con-
fronting ultimate concerns rather than coping with immediate problems. Rather
than being solution-oriented, existential therapy is aimed toward removing road-
blocks to meaningful living and helping clients assume responsibility for their
actions (Yalom & Josselson, 2014). Existential therapists assist people in facing life
with courage, hope, and a willingness to find meaning in life. Deurzen and Adams
(2011) maintain that a therapist must resonate with the client’s experience and
struggle to face life honestly. This capacity for resonance must be honed constantly,
and it requires the therapist to be fully present with the client and take part in the
therapeutic encounter in a fully engaged manner.
Relationship Between Therapist and Client
Existential therapists give central prominence to their relationship with the
client. The relationship is important in itself because the quality of this person-to-
person encounter in the therapeutic situation is the stimulus for positive change.
Attention is given to the client’s immediate, ongoing experience, especially what is
going on in the interaction between the therapist and the client. Therapy is viewed
as a social microcosm in the sense that the interpersonal and existential problems
of the client will become apparent in the here and now of the therapy relationship
(Yalom & Josselson, 2014).
Therapists with an existential orientation believe their basic attitudes toward
the client and their own personal characteristics of honesty, integrity, and courage
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E X I S T E n T I A l T H E R A P y 149
are what they have to offer. Therapy is a journey taken by therapist and client that
delves deeply into the world as perceived and experienced by the client. But this type
of quest demands that therapists also be in contact with their own phenomeno-
logical world. Existential therapy is a voyage into self-discovery and a journey of life-
discovery for both client and therapist (Deurzen, 2010; Yalom & Josselson, 2014).
Buber’s (1970) conception of the I/Thou relationship has significant implica-
tions here. His understanding of the self is based on two fundamental relationships:
the I/it and the I/Thou. The I/it is the relation to time and space, which is a necessary
starting place for the self. The I/Thou is the relationship essential for connecting the
self to the spirit and, in so doing, to achieve true dialogue. This form of relation-
ship is the paradigm of the fully human self, the achievement of which is the goal
of Buber’s existential philosophy. Relating in an I/Thou fashion means that there is
direct, mutual, and present interaction. Rather than prizing therapeutic objectivity
and professional distance, existential therapists strive to create caring and intimate
relationships with clients.
The core of the therapeutic relationship is respect, which implies faith in clients’
potential to cope authentically with their troubles and in their ability to discover
alternative ways of being. Existential therapists share their reactions to clients with
genuine concern and empathy as one way of deepening the therapeutic relationship.
Therapists invite clients to grow by modeling authentic behavior. If therapists keep
themselves hidden during the therapeutic session or if they engage in inauthentic
behavior, clients will also remain guarded and persist in their inauthentic ways.
Bugental (1987) emphasizes the crucial role the presence of the therapist plays
in the therapeutic relationship. In his view many therapists and therapeutic systems
overlook its fundamental importance. He contends that therapists are too often so
concerned with the content of what is being said that they are not aware of the dis-
tance between themselves and their clients. Schneider (2011) believes that the thera-
pist’s presence is both a condition and a goal of therapeutic change. Presence serves
the dual functions of reconnecting people to their pain and to attuning them to the
opportunities to transform their pain.
Application: Therapeutic Techniques and Procedures
The existential approach is unlike most other therapies in that it is not technique-
oriented. Although existentially oriented therapists may incorporate many tech-
niques from other models, these interventions are made within the context of striving
to understand the subjective world of the client. The interventions existential practi-
tioners employ are based on philosophical views about the nature of human existence.
These practitioners prefer description, understanding, and exploration of the client’s
subjective reality, as opposed to diagnosis, treatment, and prognosis (Deurzen, 2002).
“Existential therapists prefer to be thought of as philosophical companions, not
as people who repair psyches” (Vontress, 2013, p. 150). Yalom and Josselson (2014)
describe existential therapists as “fellow travelers” who are willing to make them-
selves known through appropriate self-disclosure. It is not theories and techniques
that heal but the encounter that occurs between client and therapist as they work
together (Elkins, 2007, 2016). Existential therapists are free to draw from techniques
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150 C H A P T E R S I X
that flow from many other orientations, but they have a set of assumptions and atti-
tudes that guide their interventions with clients. See Case Approach to Counseling and
Psychotherapy (Corey, 2013, chap. 4) for an illustration of how Dr. J. Michael Russell
works in an existential way with some key themes in the case of Ruth.
A primary ground rule of existential work is the openness to the individual cre-
ativity of the therapist and the client. Existential therapists need to adapt their inter-
ventions to their own personality and style, as well as being sensitive to what each
client requires. The main guideline is that the existential practitioner’s interventions
are responsive to the uniqueness of each client (Deurzen, 2010).
Deurzen (2012) believes that the starting point for existential work is for practi-
tioners to clarify their views on life and living. She stresses the importance of thera-
pists reaching sufficient depth and openness in their own lives to venture into clients’
murky waters without getting lost. The nature of existential work is assisting people
in the process of living with greater expertise and ease. Deurzen (2010) identifies
how therapists make a difference with clients: “We help them to get better at reflect-
ing on their situation, deal with their dilemma, face their predicament and think for
themselves” (p. 236). Deurzen reminds us that existential therapy is a collaborative
adventure in which both client and therapist will be transformed if they allow them-
selves to be touched by life. When the deepest self of the therapist meets the deepest
part of the client, the counseling process is at its best. Therapy is a creative, evolving
process of discovery that can be conceptualized in three general phases.
Phases of Existential Counseling
During the initial phase of counseling, therapists assist clients in identifying
and clarifying their assumptions about the world. Clients are invited to define and
question the ways in which they perceive and make sense of their existence. They
examine their values, beliefs, and assumptions to determine their validity. This is
a difficult task for many clients because they may initially present their problems
as resulting almost entirely from external causes. They may focus on what other
people “make them feel” or on how others are largely responsible for their actions
or inaction. The counselor teaches them how to reflect on their own existence and
to examine their role in creating their problems in living.
During the middle phase of existential counseling, clients are assisted in more
fully examining the source and authority of their present value system. This process
of self-exploration typically leads to new insights and some restructuring of values
and attitudes. Individuals get a better idea of what kind of life they consider worthy
to live and develop a clearer sense of their internal valuing process.
The final phase of existential counseling focuses on helping people take what
they are learning about themselves and put it into action. Transformation is not
limited to what takes place during the therapy hour. The therapeutic hour is a small
contribution to a person’s renewed engagement with life, or a rehearsal for life
(Deurzen, 2002). The aim of therapy is to enable clients to discover ways of imple-
menting their examined and internalized values in a concrete way between sessions
and after therapy has terminated. Clients typically discover their strengths and find
ways to put them to the service of living a purposeful existence.
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E X I S T E n T I A l T H E R A P y 151
Clients Appropriate for Existential Counseling
Existential practice has been applied in a variety of settings and with a diverse pop-
ulation of clients, including those with substance abuse issues, ethnic and racial
minorities, gay and lesbian clients, and psychiatric inpatients (Schneider, 2011). A
strength of the perspective is its focus on available choices and pathways toward
personal growth. For people who are coping with developmental crises, experienc-
ing grief and loss, confronting death, or facing a major life decision, existential
therapy is especially appropriate. Some examples of these critical turning points
that mark passages from one stage of life into another are the struggle for identity
in adolescence, coping with possible disappointments in middle age, adjusting to
children leaving home, coping with failures in marriage and work, and dealing with
increased physical limitations as one ages. These developmental challenges involve
both dangers and opportunities. Uncertainty, anxiety, and struggling with decisions
are all part of this process.
Deurzen (2002) suggests that this form of therapy is most appropriate for clients
who are committed to dealing with their problems about living, for people who feel
alienated from the current expectations of society, or for those who are searching for
meaning in their lives. It tends to work well with people who are at a crossroads and
who question the state of affairs in the world and are willing to challenge the status
quo. It can be useful for people who are on the edge of existence, such as those who
are dying or contemplating suicide, who are working through a developmental or
situational crisis, who feel that they no longer belong in their surroundings, or who
are starting a new phase of life.
Application to Brief Therapy
The existential approach can focus clients on significant areas such as assum-
ing personal responsibility, making a commitment to deciding and acting, and
expanding their awareness of their current situation. It is possible for a time-lim-
ited approach to serve as a catalyst for clients to become actively and fully involved
in each of their therapy sessions. Sharp and Bugental (2001) maintain that short-
term applications of the existential approach require more structuring and clearly
defined and less ambitious goals. At the termination of short-term therapy, it is
important for individuals to evaluate what they have accomplished and what issues
may need to be addressed later. It is essential that both therapist and client deter-
mine that short-term work is appropriate, and that beneficial outcomes are likely.
Application to Group Counseling
An existential group can be described as people making a commitment to
a lifelong journey of self-exploration with these goals: (1) enabling members to
become honest with themselves, (2) widening their perspectives on themselves and
the world around them, and (3) clarifying what gives meaning to their present and
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152 C H A P T E R S I X
future life (Deurzen, 2002). An open attitude toward life is essential, as is the will-
ingness to explore unknown territory. Recurring universal themes evolve in many
groups that challenge members to seriously explore existential concerns such as
the ability to choose a path in life, freedom and anxiety, how to live a meaningful
life in the face of the reality of death, and how to establish authentic and mutual
relationships (Leszcz, 2015). The heart of the work in an existential group is reduc-
ing avoidance of universal existential concerns because not addressing these themes
diminishes one’s engagement with life. The group leader is generally more of a
participant-observer who engages as an informed fellow traveler rather than as an
aloof sage. Leszcz (2015) notes that the leader engages in appropriate self-disclosure
and transparency, gives feedback, and shares his or her reactions within the group.
Leader disclosures center on the members’ interests rather than on the leader’s
needs or interests.
The existential group provides the optimal conditions for therapeutic work on
responsibility. The members are responsible for the way they behave in the group,
and this provides a mirror for how they are likely to act in the world. A group repre-
sents a microcosm of the world in which participants live and function. A group can
be instrumental in helping members see how some of the self-constricting patterns
they manifest in the group parallel patterns in their everyday life. Over time the
interpersonal and existential problems of the participants become evident in the
here-and-now interactions within the group (Yalom & Josselson, 2014). Through
feedback, members learn to view themselves through others’ eyes, and they learn
the ways in which their behavior affects others. Building on what members learn
about their interpersonal functioning in the group, they can take increased respon-
sibility for making changes in everyday life. The group experience provides the
opportunity to participants to relate to others in meaningful ways, to learn to be
themselves in the company of other people, and to establish rewarding, nourishing
relationships.
In existential group counseling, members come to terms with the paradoxes of
existence: that life can be undone by death, that success is precarious, that we are
determined to be free, that we are responsible for a world we did not choose, that we
must make choices in the face of doubt and uncertainty. Members experience anxi-
ety when they recognize the realities of the human condition, including pain and
suffering, the need to struggle for survival, and their basic fallibility. Clients learn
that there are no ultimate answers for ultimate concerns. Through the support that
is within a group, participants are able to tap the strength needed to create an inter-
nally derived value system that is consistent with their way of being.
A group provides a powerful context to look at oneself, and to consider what
choices might be more authentically one’s own. Members can openly share their
fears related to living in unfulfilling ways and come to recognize how they have com-
promised their integrity. Members can gradually discover ways in which they have
lost their direction and can begin to be more true to themselves. The group becomes
a place where people can be together in deeply meaningful ways. Members learn that
it is not in others that they find the answers to questions about significance and pur-
pose in life. Existential group leaders help members live in authentic ways and refrain
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E X I S T E n T I A l T H E R A P y 153
from prescribing simple solutions. For a more detailed discussion of the existential
approach to group counseling, see Corey (2016, chap. 9).
Existential Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
Because the existential approach does not dictate a particular way of viewing
or relating to reality, and because of its broad perspective, this approach is highly
relevant in working in a multicultural context (Deurzen, 2012). Vontress and col-
leagues (1999) write about the existential foundation of cross-cultural counseling:
“Existential counseling is probably the most useful approach to helping clients
of all cultures find meaning and harmony in their lives, because it focuses on the
sober issues each of us must inevitably face: love, anxiety, suffering, and death”
(p. 32). These are the human experiences that transcend the boundaries that sepa-
rate cultures.
Existential therapy emphasizes presence, the I/Thou relationship, and courage.
As such, it can be effectively applied with diverse client populations with a range of
specific problems and in a wide array of settings (Schneider, 2008, 2011; Schneider
& Krug, 2010). Schneider’s (2008) “existential-integrative” model of practice coordi-
nates a variety of therapeutic modes within an overarching existential or experiential
framework. Vontress (2013) believes existential therapy is especially useful in work-
ing with culturally diverse populations because of its focus on universality, or the
similarities we all share. He encourages counselors-in-training to focus on the univer-
sal commonalities of clients first and secondarily on areas of differences. In working
with cultural diversity, it is essential to recognize how we are both alike and different.
The existential focus on subjective experience, or phenomenology, is a strength
from a multicultural perspective. Another strength consists of inviting clients to
examine the degree to which their behavior is being influenced by social and cul-
tural conditioning. Clients can be challenged to look at the price they are paying for
the decisions they have made. Although it is true that some clients may not feel a
sense of freedom, their freedom can be increased if they recognize the social limits
they are facing. Their freedom can be hindered by institutions and limited by their
family. In fact, it may be difficult to separate individual freedom from the context
of their family structure.
There is wide-ranging international interest in the existential approach. Several
Scandinavian societies, an East European society (encompassing Estonia, Latvia,
Lithuania, Russia, Ukraine, and Belarus), and Mexican and South American societ-
ies are thriving. In addition, an Internet course, SEPTIMUS, is taught in Ireland,
Iceland, Sweden, Poland, Czech Republic, Romania, Italy, Portugal, Austria, France,
Belgium, the United Kingdom, Israel, and Australia. Most recently, the First Inter-
national East-West Existential Psychology conference was held in Nanjing, China,
with representatives from the United States, Korea, and Japan. The International
Collaborative of Existential Counsellors and Psychotherapists (ICECAP) meets
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154 C H A P T E R S I X
online and hosts international conferences as well. The existential movement in the
United Kingdom is thriving, and several doctoral programs are offered. These inter-
national developments confirm that existential therapy has wide appeal for diverse
populations in many parts of the world.
Shortcomings From a Diversity Perspective
For those who hold a systemic perspective, the existentialists can be criticized on
the grounds that they are excessively individualistic and ignore the social factors
that cause human problems. However, with the advent of the “existential-integrative”
model of practice (Schneider, 2008), this situation is beginning to change. According
to Schneider (2011), existential practitioners are not only concerned with facilitat-
ing individual change but with promoting an in-depth inquiry that has implica-
tions for social change: “One cannot simply heal individuals to the neglect of the
social context within which they are thrust. To be a responsible practitioner, one
must develop a vision of responsible social change alongside and in coordination
with one’s vision of individual transformation” (p. 281).
Some individuals who seek counseling may operate on the assumption that
they have very little choice because environmental circumstances severely restrict
their ability to influence the direction of their lives. Even if they change internally,
they see little hope that the external realities of racism, discrimination, and oppres-
sion will change. They are likely to experience a deep sense of frustration and feel-
ings of powerlessness when it comes to making changes outside of themselves. As
you will see in Chapter 12, feminist therapists maintain that therapeutic practice
will be effective only to the extent that therapists intervene with some form of
social action to change those factors that are creating clients’ problems. In work-
ing with people of color who come from the barrio or ghetto, for example, it is
important to engage their survival issues. If a counselor too quickly puts across the
message to these clients that they have a choice in making their lives better, they
may feel patronized and misunderstood. These real-life concerns can provide a good
focus for counseling, assuming the therapist is willing to deal with them.
A potential problem within existential theory is that it is highly focused on the
philosophical assumption of self-determination, which may not take into account
the complex factors that many people who have been oppressed must deal with. In
many cultures it is not possible to talk about the self and self-determination apart
from the context of the social network and environmental conditions. However, a
case can be made for the existential approach being instrumental in enabling cli-
ents to make conscious choices when it comes to the values they live by. Existential
therapists do not push autonomy apart from a client’s culture. They do assist clients
in critically evaluating the source of their values and making a choice rather than
uncritically accepting the values of their culture and family.
Many clients expect a structured and problem-oriented approach to counseling
that is not found in the conventional existential approach. Although clients may
feel better if they have an opportunity to talk and to be understood, they are likely to
expect the counselor to do something to bring about a change in their life situation.
A major task for the counselor who practices from an existential perspective is to
provide enough concrete direction for these clients without taking the responsibil-
ity away from them.
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A s an existentially oriented therapist, I counsel Stan with the assumption that he has the capac-
ity to increase his self-awareness and decide for himself
the future direction of his life. I want him to realize
more than anything else that he does not have to be
the victim of his past conditioning but can be the ar-
chitect in redesigning his future. He can free himself
of his deterministic shackles and accept the respon-
sibility that comes with directing his own life. This
approach emphasizes the importance of my under-
standing of Stan’s world, primarily by establishing an
authentic relationship as a means to a fuller degree of
self-understanding.
Stan is demonstrating what Sartre would call
“bad faith” by not accepting personal responsibility. I
confront Stan with the ways in which he is attempt-
ing to escape from his freedom through alcohol and
drugs. Eventually, I challenge Stan’s passivity. I reaf-
firm that he is now entirely responsible for his life, for
his actions, and for his failure to take action. I do this
in a supportive yet firm manner.
I do not see Stan’s anxiety as something nega-
tive, but as a vital part of living with uncertainty and
freedom. Because there are no guarantees and because
the individual is ultimately alone, Stan can expect to
experience some degree of healthy anxiety, aloneness,
guilt, and even despair. These conditions are not neu-
rotic in themselves, but the way in which Stan orients
himself and copes with these conditions is critical.
Stan sometimes talks about his suicidal feelings.
Certainly, I investigate further to determine if he poses
an immediate threat to himself. In addition to this as-
sessment to determine lethality, I view his thoughts of
“being better off dead” as symbolic. Could it be that
Stan feels he is dying as a person? Is Stan using his hu-
man potential? Is he choosing a way of merely existing
instead of affirming life? Is Stan mainly trying to elicit
sympathy from his family? I invite Stan to explore the
meaning and purpose in his life. Is there any reason for
him to want to continue living? What are some of the
projects that enrich his life? What can he do to find a
sense of purpose that will make him feel more signifi-
cant and alive?
Stan needs to accept the reality that he may at
times feel alone. Choosing for oneself and living from
one’s own center accentuates the experience of alone-
ness. He is not, however, condemned to a life of isola-
tion, alienation from others, and loneliness. I hope to
help Stan discover his own centeredness and live by the
values he chooses and creates for himself. By doing so,
Stan can become a more substantial person and come
to appreciate himself more. When he does, the chances
are lessened that he will have a need to secure approv-
al from others, particularly his parents and parental
substitutes. Instead of forming a dependent relation-
ship, Stan could choose to relate to others out of his
strength. Only then would there be the possibility of
overcoming his feelings of separateness and isolation.
Questions for Reflection
�� If Stan resisted your attempts to help him see that
he is responsible for the direction of his life, how
might you intervene?
�� Stan experiences a great deal of anxiety. From an
existential perspective, how do you view his anxi-
ety? How might you work with his anxiety in help-
ful ways?
�� If Stan talks with you about suicide as a response
to despair and a life without meaning, how would
you respond?
Existential Therapy Applied to the Case of Stan
Visit CengageBrain.com or watch the DVD for
the video program Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes,
Session 4 (existential therapy), for a demonstra-
tion of my approach to counseling Stan from this
perspective. This session focuses on the themes
of death and the meaning of life.
E X I S T E n T I A l T H E R A P y 155
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156 C H A P T E R S I X
I n working with Gwen from an existential approach, I want to be a witness to her subjective experience
of the world and assist her in exploring powerful life
themes such as meaning making, the inevitability of
death, freedom, choice, and responsibility. It is im-
portant for me to hear and understand the concerns
Gwen brings to this session. As Gwen walks into my
office, I observe her rounded shoulders and feel the
heaviness of her emotions.
Therapist: Tell me what you are experiencing
[phenomenological inquiry].
Gwen: I feel overwhelmed, shut down, sad,
and exhausted.
Therapist: The feelings you describe sound
similar to your feelings when you first
began counseling: numbness, feeling like
your life is a flat note with little joy.
Gwen: Yes! I am tired of the violence. I am
tired of young black men that look like
my son losing their lives. This has got to
stop. Something has to change in our
country, and I don’t mean on the surface.
Something has really got to change.
Therapist: I hear you.
Gwen: I can’t even sleep at night. I am trying
not to watch the news because young
people dying seems like an everyday
occurrence. It’s not fair. Life cut short by
ignorance and injustice. When I haven’t
heard from my children in a while, I get a
hole in the pit of my stomach. I am just sick
thinking I will lose my child.
I am focused on being present for Gwen as she
grapples with these challenging existential themes
in her life. I listen to Gwen’s personal stories of rac-
ism and injustice and her search for meaning. She
describes her anxiety as being like a fog that is always
there and that no one can do anything about. Her
sense of helplessness and fear of death for her son is
real. I assist Gwen in seeing that she has options in
how she confronts experiences of injustice and unfair-
ness as they occur in her life. As Gwen explores and
expresses her anxieties and fears, she begins to real-
ize she has the power and freedom to create meaning
from the circumstances that arise in her life. Even
those events and experiences that bring her pain can
assist her in taking more control of her circumstances
and living in a more vital manner.
Gwen: Worrying keeps me up much of
the night. I end up feeling scared and
depressed, and then I get into this whole
spiral where everything feels wrong. Life is
so fragile and can be cut short in a blink.
Therapist: It seems as though you have come
to the realization that we are finite and that
time is limited, and that’s frightening and
anxiety producing.
Gwen: I feel helpless. I fear for my son’s life
and feel like there is nothing I can do to
protect him.
Therapist: With these intense feelings of
helplessness, fear, and anxiety, how do you
even get through your day?
Gwen: I have been through a lot and I
have survived. Even though I have my
fears, I surprise myself and bounce back
eventually. At the end of the day, it’s my
faith and the knowledge that I am making
a difference in the world by passing my
faith on to my children that helps me
move forward.
As an existential practitioner, I share with Gwen
that anxiety is a natural part of life and that death
awareness is a powerful force that can assist us in liv-
ing a fuller existence. In our awareness of our own
mortality, we can decide to take charge of our life and
make choices that enhance our existence. Gwen begins
to see that her experience of anxiety may be a key to
informing her of exactly how she might begin to do
things differently in her life.
Existential Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from an existential perspective and applying this model to Gwen.
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Summary and Evaluation
Summary
Existential therapists believe we all are capable of self-awareness, which is the dis-
tinctive capacity that allows us to reflect and to decide. With this awareness we
become free beings who are responsible for choosing the way we live, and we influ-
ence our own destiny. This awareness of freedom and responsibility gives rise to
existential anxiety, which is another basic human characteristic. Whether we like it
or not, we are free, even though we may seek to avoid reflecting on this freedom. The
knowledge that we must choose, even though the outcome is not certain, leads to
anxiety. This anxiety is heightened when we reflect on the reality that we are mortal.
Facing the inevitable prospect of eventual death gives the present moment signifi-
cance, for we become aware that we do not have forever to accomplish our projects.
As humans we are unique in that we strive toward fashioning purposes and values
that give meaning to living. Whatever meaning our life has is developed through
freedom and a commitment to make choices in the face of uncertainty.
Existential therapy places central prominence on the person-to-person relation-
ship. It assumes that client growth occurs through this genuine encounter. It is not
the techniques a therapist uses that make a therapeutic difference; rather, it is the
quality of the client–therapist relationship that heals (Elkins, 2016). It is essential
that therapists reach sufficient depth and openness in their own lives to allow them to
venture into their clients’ subjective world without losing their own sense of identity.
Presence is both a condition for therapy to occur and a goal of therapy. Existential
therapists strive to be authentic and self-disclosing in their therapy work. Because
this approach focuses on the goals of therapy, basic conditions of being human,
and therapy as a shared journey, practitioners are not bound by specific techniques.
Although existential therapists may apply techniques from other orientations, their
interventions are guided by a philosophical framework about what it means to be
human.
As our session comes to a close, I remind Gwen of
the powerful themes that surfaced in her session and
her ability to identify as a strong, spiritual, resilient
woman. I support her decision to journal more of her
thoughts and feelings about what gives meaning and
joy to her life and how she can make a difference in
these challenging times.
Questions for Reflection
�� What existential questions is Gwen facing
in her life?
�� How would you experience being in the room
with Gwen during this session? What may sur-
face for you as you sit with her?
�� How can awareness of the fragility of life be a cata-
lyst for making decisions about how to live more
fully? Have you ever lost someone close to you?
What decisions did you make?
�� Gwen has talked about her loneliness and isola-
tion, which are part of the human condition.
How do you think an existential approach can
help Gwen deal with this issue?
E X I S T E n T I A l T H E R A P y 157
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158 C H A P T E R S I X
Contributions of the Existential Approach
The existential approach has helped bring the person back into central
focus. It concentrates on the central facts of human existence: self-consciousness
and our consequent freedom. To the existentialist goes the credit for providing a
new view of death as a positive force, not a morbid prospect to fear, for death gives
life meaning. Existentialists have contributed a new dimension to the understand-
ing of anxiety, guilt, frustration, loneliness, and alienation.
I particularly appreciate the way Deurzen (2012) views the existential practi-
tioner as a mentor and fellow traveler who encourages people to reflect upon the
problems they encounter in living. What clients need is “some assistance in survey-
ing the terrain and in deciding on the right route so that they can again find their
way” (p. 30). The existential approach encourages people to live life by their own
standards and values.
One of the major contributions of the existential approach is its emphasis on
the human quality of the therapeutic relationship. This aspect lessens the chances of
dehumanizing psychotherapy by making it a mechanical process. Existential coun-
selors reject the notions of therapeutic objectivity and professional distance, viewing
them as being unhelpful.
I very much value the existential emphasis on freedom and responsibility and
the person’s capacity to redesign his or her life by choosing with awareness. This
perspective provides a sound philosophical base on which to build a personal and
unique therapeutic style because it addresses itself to the core struggles of the con-
temporary person.
Contributions to the Integration of Psychotherapies From my perspective, the
key concepts of the existential approach can be integrated into most therapeutic
schools. Regardless of a therapist’s orientation, the foundation for practice can be
based on existential themes. Existential psychotherapy continues to have an enduring
impact on a variety of psychological practices. “Indeed, existential psychotherapy is
in the ironic position of being one of the most widely influential yet least officially
embraced orientations on the professional scene” (Schneider, 2008, p. 1).
A key contribution is the possibility of a creative integration of the concep-
tual propositions of existential therapy with many other therapeutic orientations
(Bugental & Bracke, 1992; Schneider, 2008, 2011; Schneider & Krug, 2010). One
example of such a creative integration is provided by Dattilio (2002), who integrates
cognitive behavioral techniques with the themes of an existential approach. As a
cognitive behavior therapist and author, Dattilio maintains that he directs much of
his efforts to “helping clients make a deep existential shift—to a new understanding
of the world” (p. 75). He uses techniques such as restructuring of belief systems,
relaxation methods, and a variety of cognitive and behavioral strategies, but he does
so within an existential framework that can begin the process of real-life transfor-
mation. Many of his clients suffer from panic attacks or depression. Dattilio often
explores with these people existential themes of meaning, guilt, hopelessness, anxi-
ety—and at the same time he provides them with cognitive behavioral tools to cope
with the problems of daily living. In short, he grounds symptomatic treatment in an
existential approach.
LO10
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E X I S T E n T I A l T H E R A P y 159
Some people have argued that the new trend toward positive psychology is
similar to the existential approach, but this rests on a superficial comparison of
these two approaches. Existential therapists favor intensity and passionate experi-
ence, including that of happiness, but they equally value the darker side of human
nature and would encourage clients to learn to value both sides of their experience
(Deurzen, 2009).
Limitations and Criticisms of the Existential Approach
A major criticism often aimed at this approach is that it lacks a systematic state-
ment of the principles and practices of psychotherapy. Some practitioners have
trouble with what they perceive as its mystical language and concepts. Some thera-
pists who claim adherence to an existential orientation describe their therapeutic
style in vague and global terms such as self-actualization, dialogic encounter, authenticity,
and being in the world. This particular use of language causes confusion at times and
makes it difficult to conduct research on the process or outcomes of existential
therapy.
Both beginning and advanced practitioners who are not of a philosophical turn
of mind tend to find many of the existential concepts lofty and elusive. As we have
seen, this approach places primary emphasis on a subjective understanding of the
world of clients. It is assumed that techniques follow understanding. The fact that
few techniques are generated by this approach makes it essential for practitioners to
develop their own innovative procedures or to borrow from other schools of therapy.
For counselors who believe they need a specific set of techniques to counsel effec-
tively, this approach has limitations (Vontress, 2013).
Practitioners who prefer a counseling practice based on research contend that
the concepts should be empirically sound, that definitions should be operational,
that the hypotheses should be testable, and that therapeutic practice should be
based on the results of research into both the process and outcomes of counseling.
Certainly, the notions of manualized therapy and evidence-based practice are not
part of the existential perspective because every psychotherapy experience is unique
(Walsh & McElwain, 2002). According to Cooper (2003), existential practitioners
generally reject the idea that the therapeutic process can be measured and evalu-
ated in quantitative and empirical ways. Although existential practices are generally
upheld in recent research on therapeutic effectiveness (see Elkins, 2009), few studies
directly evaluate and examine the existential approach. To a large extent, existential
therapy makes use of techniques from other theories, which makes it difficult to
apply research to thiss approach to study its effectiveness (Sharf, 2016).
According to Deurzen (2002), the main limitation of this approach is that of
the level of maturity, life experience, and intensive training required of practitioners.
Existential therapists need to be wise and capable of profound and wide-ranging
understanding of what it means to be human. Authenticity is a cardinal character-
istic of a competent existential practitioner, which is certainly more involved than
mastering a body of knowledge and acquiring technical skills. Russell (2007) puts
this notion nicely: “Authenticity means being able to sign your own name on your
work and your life. It means you will want to take responsibility for creating your
own way of being a therapist” (p. 123).
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160 C H A P T E R S I X
Self-Reflection and Discussion Questions
1. Identify at least one turning point in your life. What decision did
you make at this time, and how has this influenced the person you
are today?
2. What does existential anxiety mean to you? How do you deal with this
kind of anxiety in your life?
3. Existential therapy provides a philosophy and a framework for psycho-
therapy, but few techniques. How can you have an existential orienta-
tion and at the same time incorporate techniques from other therapy
models?
4. Existential themes have relevance for working with a range of clients
with a variety of problems in various settings. What one existential
theme do you believe is a key issue for many people today?
5. How would you work with a client who has little interest in exploring
existential themes and asks for advice on how to deal with some con-
crete problem?
Where to Go From Here
Refer to the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, Session 11
(“Understanding How the Past Influences the Present and the Future”), for a dem-
onstration of ways I utilize existential notions in counseling Ruth. We engage in a
role play where Ruth becomes the voice of her church and I take on a new role as
Ruth—one in which I have been willing to challenge certain beliefs from church.
This segment illustrates how I assist Ruth in finding new values. In Session 12
(“Working Toward Decisions and Behavioral Changes”) I challenge Ruth to make
new decisions, which is also an existential concept.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 6, Existential
Therapy, look for Podcast 14 by Dr. Gerald Corey.
Other Resources
The American Psychological Association offers a DVD by K. J. Schneider (2009)
titled Existential-Humanistic Therapy in their Systems of Psychotherapy Video Series.
Psychotherapy.net is a comprehensive resource for students and profession-
als that offers videos and interviews on existential therapy featuring Irvin Yalom,
James Bugental, and Rollo May. New video and editorial content is made available
monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and
include the following:
Bugental, J. F. T. (1995). Existential-Humanistic Psychotherapy in Action
Bugental, J. (1997). Existential-Humanistic Psychotherapy (Psychotherapy with
the Experts Series)
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E X I S T E n T I A l T H E R A P y 161
Bugental, J. (2008). James Bugental: Live Case Consultation
May, R. (2007). Rollo May on Existential Psychotherapy
Yalom, I. (2002). The Gift of Therapy: A Conversation with Irvin Yalom, MD
Yalom, I. (2006). Irvin Yalom: Live Case Consultation
Yalom, I. (2011). Confronting Death and Other Existential Issues in
Psychotherapy
If you are interesting in further information on Irvin Yalom, check out his website.
Irvin Yalon
www.yalom.com
The Existential-Humanistic Institute’s (EHI) primary focus is training; the insti-
tute offers courses and, in conjunction with Saybrook University, a new certificate
program in existential-humanistic therapy and theory. A secondary focus is commu-
nity building. EHI was formed as a nonprofit organization under the auspices of the
Pacific Institute in 1997 and provides a home for those mental health professionals,
scholars, and students who seek in-depth training in existential-humanistic theory
and practice. EHI’s year-long certificate program offers graduate and postgraduate
students an opportunity to gain a basic foundation in the theory and practice of
existential-humanistic therapy. EHI offers courses on the principles of existential-
humanistic practice and case seminars in existential-humanistic theory and prac-
tice. Most of EHI’s instructors have studied extensively with such masters as James
Bugental, Irvin Yalom, and Rollo May, and are, like Kirk Schneider and Orah Krug,
acknowledged leaders of the existential-humanistic movement today.
The Existential-Humanistic Institute
www.ehinstitute.org
The Society for Existential Analysis is a professional organization devoted to
exploring issues pertaining to an existential/phenomenological approach to coun-
seling and therapy. Membership is open to anyone interested in this approach and
includes students, trainees, psychotherapists, philosophers, psychiatrists, counsel-
ors, and psychologists. Members receive a regular newsletter and an annual copy of
the Journal of the Society for Existential Analysis. The society provides a list of existen-
tially oriented psychotherapists for referral purposes. The School of Psychotherapy
and Counselling at Regent’s University in London offers an advanced diploma in
existential psychotherapy as well as short courses in the field. Additional Informa-
tion is available at www.dilemmas.org.
Society for Existential Analysis
www.existentialanalysis.co.uk/
The International Society for Existential Psychotherapy and Counselling was
created in London in July 2006 and was renamed International Collaborative of
Existential Counselors and Psychotherapists soon after (www.icecap.org.uk). It
brings together the existing national societies as well as providing a forum for the
development and accreditation of the approach.
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162 C H A P T E R S I X
International Society for Existential Psychotherapy and Counselling
www.existentialpsychotherapy.net
SEPTIMUS is an Internet-based course taught in Ireland, Iceland, Sweden,
Poland, Czech Republic, Romania, Italy, Portugal, Austria, Belgium, France, Israel,
Australia, and the United Kingdom. Additional Information is available at www
.psychotherapytraining.net.
Psychotherapy Training on the Net: SEPTIMUS
www.septimus.info
The New School of Psychotherapy and Counselling (NSPC) now offers two doc-
toral programs: one in existential psychotherapy and one in existential counselling
psychology. NSPC offers intensive courses for distance learners (worldwide student
body) including e-learning.
New School of Psychotherapy and Counselling
www.nspc.org.uk
Recommended Supplementary Readings
Everyday Mysteries: A Handbook of Existential Psycho-
therapy (Deurzen, 2010) provides a framework for
practicing counseling from an existential perspec-
tive. The author puts into clear perspective topics
such as anxiety, authentic living, clarifying one’s
worldview, determining values, discovering mean-
ing, and coming to terms with life.
Existential Counselling and Psychotherapy in Practice
(Deurzen, 2012) offers an excellent presentation of
the theory and practice of existential therapy based
on the European tradition. The author provides a
framework for addressing problems in living rather
than techniques for working with clients.
Skills in Existential Counselling and Psychotherapy
(Deurzen & Adams, 2011) is a clearly written book
that explains the existential attitude, highlights
the importance of the person of the therapist, and
describes the process of existential therapy. This is
a superb resource that provides a basis for under-
standing how to apply existential notions to thera-
peutic practice.
Existential Therapies (Cooper, 2003) provides a use-
ful and clear introduction to the existential thera-
pies. There are separate chapters on logotherapy, the
British school of existential analysis, the American
existential-humanistic approach, dimensions of
existential therapeutic practice, and brief existential
therapies.
Existential Psychotherapy (Yalom, 1980) is a superb
treatment of the ultimate human concerns of death,
freedom, isolation, and meaninglessness as these
issues relate to therapy. This book has depth and
clarity, and it is rich with clinical examples that illus-
trate existential themes.
Existential-Humanistic Therapy (Schneider & Krug,
2010) is a clear presentation of the theory and
practice of existential-humanistic therapy. This
approach incorporates techniques from other con-
temporary therapeutic approaches.
Existential-Integrative Psychotherapy: Guideposts to the
Core of Practice (Schneider, 2008) is an edited book
that offers recent and future trends in existential-
integrative therapy and case illustrations of this
model.
I Never Knew I Had a Choice (Corey & Corey, 2014) is
a self-help book written from an existential perspec-
tive. Topics include our struggle to achieve auton-
omy; the meaning of loneliness, death, and loss; and
how we choose our values and philosophy of life.
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163
7Person-Centered Therapy
1. Examine the evolution of person-
centered therapy over time.
2. Describe the main thrust of
emotion-focused therapy.
3. Differentiate the contributions
of Carl Rogers and Abraham
Maslow to humanistic
psychology.
4. Understand the role of the
therapist’s attitudes in the therapy
process.
5. Describe the ways that empathy,
unconditional positive regard,
and genuineness are fundamental
to the process and outcome
of therapy.
6. Identify the personal characteristics
of therapists that are essential for
clients’ progress.
7. Examine the application of the
person-centered approach to crisis
intervention.
8. Understand the unique
characteristics of person-centered
expressive arts and how it is based
on person-centered philosophy.
9. Examine the key concepts
and principles of motivational
interviewing and the stages
of change.
10. Recognize the contributions
and shortcomings of the
person-centered approach to
understanding and working with
clients from diverse cultures.
11. Identify the contributions and
limitations of the person-centered
approach.
L e a r n i n g O b j e c t i v e s
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164 C H A P T E R S E V E N
CARL ROGERS (1902–1987), a major
spokesperson for humanistic psychol-
ogy, led a life that reflected the ideas he
developed for half a century. He showed
a questioning stance, a deep openness
to change, and the courage to forge into
unknown territory both as a person and as
a professional. In writing about his early
years, Rogers (1961) recalled his fam-
ily atmosphere as characterized by close
and warm relationships but also by strict
religious standards. Play was discouraged,
and the virtues of the Protestant ethic
were extolled. His boyhood was somewhat lonely, and
he pursued scholarly interests instead of social ones.
Rogers was an introverted person, and he spent a lot of
time reading and engaging in imaginative activity and
reflection. During his college years his interests and
academic major changed from agriculture to history,
then to religion, and finally to clinical psychology.
Rogers held academic positions in various fields,
including education, social work, counseling, psycho-
therapy, group therapy, peace, and interpersonal rela-
tions, and he earned recognition around the world for
originating and developing the humanistic movement
in psychotherapy. His foundational ideas, especially
the central role of the client–therapist relationship as a
means to growth and change, have been incorporated
in many other theoretical approaches. Rogers’s ideas
continue to have far-reaching effects on the field of psy-
chotherapy (Cain, 2010).
It is difficult to overestimate the significance of
Rogers’s contributions to clinical and counseling
psychology. He was a courageous pioneer
who “was about 50 years ahead of his
time and has been waiting for us to catch
up” (Elkins, 2009, p. 20). Often called the
“father of psychotherapy research,” Rogers
was the first to study the counseling pro-
cess in depth by analyzing the transcripts
of actual therapy sessions, and he was
the first clinician to conduct major stud-
ies on psychotherapy using quantitative
methods. He was the first to formulate a
comprehensive theory of personality and
psychotherapy grounded in empirical
research, and he contributed to developing a theory
of psychotherapy that focused on the strengths and
resources of individuals. He was not afraid to take
a strong position and challenged the status quo
throughout his professional career.
During the last 15 years of his life, Rogers applied
the person-centered approach to world peace by train-
ing policymakers, leaders, and groups in conflict.
Perhaps his greatest passion was directed toward the
reduction of interracial tensions and the effort to
achieve world peace, for which he was nominated for
the Nobel Peace Prize.
For a detailed video presentation of the life and
works of Carl Rogers, see Carl Rogers: A Daughter’s
Tribute (N. Rogers, 2002), which is described at the
end of this chapter. For an in-depth look at this
remarkable man and his work, see Carl Rogers: The
Quiet Revolutionary (Rogers & Russell, 2002) and
The Life and Work of Carl Rogers (Kirschenbaum,
2009).
NATALIE ROGERS (b. 1928) is a pioneer
in the field of person-centered expres-
sive arts therapy. She expanded on her
father’s (Carl Rogers) theory of cre-
ativity by using the expressive arts to
enhance personal growth for individuals
and groups. Person-centered expres-
sive arts therapy employs a variety of
forms—movement, painting, sculpting,
music, writing, and improvisation—in a
supportive setting to facilitate growth
and healing. It extends person-centered
theory by helping individuals access their
feelings through creative expressions.
N. Rogers has developed the concept of
the creative connection®—a process
whereby the client or group member is
invited to access inner feelings through
an uninterrupted sequence of movement,
sound, visual art, and journal writing. As
the client moves through this process,
hidden or unconscious aspects of self are
discovered, and these insights are shared
with the therapist.
Carl Rogers
Ro
ge
r R
es
sm
ey
er
/C
or
bi
s
Natalie Rogers
Fi
on
a
Ch
an
g
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P E R S o N – C E N T E R E d T H E R A P y 165
Introduction
Of all the pioneers who have founded a therapeutic approach, for me Carl Rogers
stands out as one of the most influential figures in revolutionizing the direction of
counseling theory and practice. Rogers has become known as a “quiet revolution-
ary” who both contributed to theory development and whose influence continues
to shape counseling practice today (see Cain, 2010; Kirschenbaum, 2009; Rogers &
Russell, 2002).
The person-centered approach shares many concepts and values with the exis-
tential perspective presented in Chapter 6. Rogers’s basic assumptions are that peo-
ple are essentially trustworthy, that they have a vast potential for understanding
themselves and resolving their own problems without direct intervention on the
therapist’s part, and that they are capable of self-directed growth if they are involved
in a specific kind of therapeutic relationship. From the beginning, Rogers empha-
sized the attitudes and personal characteristics of the therapist and the quality of the
client–therapist relationship as the prime determinants of the outcome of the thera-
peutic process. He consistently relegated to a secondary position matters such as
the therapist’s knowledge of theory and techniques. This belief in the client’s capac-
ity for self-healing is in contrast with many theories that view the therapist’s tech-
niques as the most powerful agents that lead to change (Bohart & Tallman, 2010).
Clearly, Rogers revolutionized the field of psychotherapy by proposing a theory that
centered on the client as the primary agent for constructive self-change (Bohart &
Tallman, 2010; Bozarth, Zimring, & Tausch, 2002; Elkins, 2016).
Contemporary person-centered therapy is the result of an evolutionary pro-
cess that continues to remain open to change and refinement (see Cain, 2010;
Cain & Seeman, 2002). Rogers did not present the person-centered theory as a
fixed and completed approach to therapy. He hoped that others would view his
theory as a set of tentative principles relating to how the therapy process devel-
ops, not as dogma. Rogers expected his model to evolve and was open and recep-
tive to change.
Visit CengageBrain.com or watch the dVd for the video program on Chapter 7, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
N. Rogers’s work evolved from what she felt was
lacking in her father’s theory. As a woman growing up in
an era when females were meant to be accommodating
to men, she eventually discovered her underlying anger
at being a second-class citizen. Her art was one vehi-
cle to express and gain insight into this injustice. She
also expressed her anger at her father because he was
unknowingly a part of the patriarchal system. He was
surprised but open to learning. After hearing about the
role he and other men played in holding women back,
he changed many of his ways of being and writing.
Today, at 87 years of age, N. Rogers continues to
find ways to bring meaning to her personal and pro-
fessional life. During the past 10 years she taught and
facilitated workshops in the United States, England,
Hong Kong, Latin America, Russia, and South Korea.
She continues to participate in teaching the six-week
expressive arts certificate program at Sofia University
in northern California. See the resources section at
the end of this chapter if you are interested in train-
ing in the person-centered approach to expressive arts
therapy.
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166 C H A P T E R S E V E N
Four Periods of Development of the Approach
In tracing the major turning points in Rogers’s approach, Zimring and
Raskin (1992) and Bozarth, Zimring, and Tausch (2002) have identified four periods
of development. In the first period, during the 1940s, Rogers developed what was
known as nondirective counseling, which provided a powerful and revolutionary alter-
native to the directive and interpretive approaches to therapy then being practiced.
While he was a professor at Ohio State University, Rogers (1942) published Counsel-
ing and Psychotherapy: Newer Concepts in Practice, which described the philosophy and
practice of nondirective counseling. Rogers’s theory emphasized the counselor’s
creation of a permissive and nondirective climate. When he challenged the basic
assumption that “the counselor knows best,” he realized this radical idea would
affect the power dynamics and politics of the counseling profession, and indeed it
caused a great furor (Elkins, 2009).
Rogers also challenged the validity of commonly accepted therapeutic proce-
dures such as advice, suggestion, direction, persuasion, teaching, diagnosis, and
interpretation. Based on his conviction that diagnostic concepts and procedures
were inadequate, prejudicial, and often misused, Rogers omitted them from his
approach. Nondirective counselors avoided sharing a great deal about themselves
with clients and instead focused mainly on reflecting and clarifying the clients’ ver-
bal communications and intended meanings.
In the second period, during the 1950s, Rogers (1951) renamed his approach
client-centered therapy, which reflected his emphasis on the client rather than on non-
directive methods. In addition, he started the Counseling Center at the University
of Chicago. This period was characterized by a shift from clarification of feelings to
a focus on the phenomenological world of the client. Rogers assumed that the best
vantage point for understanding how people behave was from their own internal
frame of reference. He focused more explicitly on the actualizing tendency as the
basic motivational force that leads to client change.
The third period, which began in the late 1950s and extended into the 1970s,
addressed the necessary and sufficient conditions of therapy. Rogers (1957) set forth
a hypothesis that resulted in three decades of research. A significant publication was
On Becoming a Person (C. Rogers, 1961), which addressed the nature of “becoming
the self that one truly is,” an idea he borrowed from Kierkegaard. Rogers published
this work during the time that he held joint appointments in the departments of
psychology and psychiatry at the University of Wisconsin. In this book he described
the process of “becoming one’s experience,” which is characterized by an openness
to experience, a trust in one’s experience, an internal locus of evaluation, and the
willingness to be in process. During the 1950s and 1960s, Rogers and his associates
continued to test the underlying hypotheses of the client-centered approach by con-
ducting extensive research on both the process and the outcomes of psychotherapy.
He was interested in how people best progress in psychotherapy, and he studied
the qualities of the client–therapist relationship as a catalyst leading to personality
change.
Rogers and his associates at the University of Chicago conducted research to
identify the ingredients in psychotherapy that account for therapeutic change. The
client-centered approach emphasized the role of the therapist as a facilitator of
LO1
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P E R S o N – C E N T E R E d T H E R A P y 167
growth and honored the inherent power of the client. Research findings consistently
supported this approach, confirming that therapeutic change is due to personal and
interpersonal factors rather than to specific techniques for curing specific disorders
(Elkins, 2016). On the basis of this research, the approach was further refined and
expanded (C. Rogers, 1961). For example, client-centered philosophy was applied to
education and was called student-centered teaching (C. Rogers & Freiberg, 1994). The
approach was also applied to encounter groups (C. Rogers, 1970).
The fourth phase, during the 1980s and the 1990s, was marked by considerable
expansion to education, couples and families, industry, groups, conflict resolution,
politics, and the search for world peace. Because of Rogers’s ever-widening scope of
influence, including his interest in how people obtain, possess, share, or surrender
power and control over others and themselves, his theory became known as the per-
son-centered approach. This shift in terms reflected the broadening application of the
approach. Although the person-centered approach has been applied mainly to indi-
vidual and group counseling, important areas of further application include educa-
tion, family life, leadership and administration, organizational development, health
care, cross-cultural and interracial activity, and international relations. During the
1980s Rogers directed his efforts toward applying the person-centered approach to
politics, especially to efforts related to the achievement of world peace.
In a comprehensive review of the research on person-centered therapy over a
period of 60 years, Bozarth, Zimring, and Tausch (2002) concluded the following:
�� In the earliest years of the approach, the client rather than the therapist
determined the direction and goals of therapy and the therapist’s role
was to help the client clarify feelings. This style of nondirective therapy
was associated with increased understanding, greater self-exploration,
and improved self-concepts.
�� Later a shift from clarification of feelings to a focus on the client’s lived
experiences took place.
�� As person-centered therapy developed further, research centered on
the core conditions assumed to be both necessary and sufficient for
successful therapy. The attitude of the therapist—an empathic under-
standing of the client’s world and the ability to communicate a non-
judgmental stance to the client—along with the therapist’s genuineness
were found to be basic to a successful therapy outcome.
�� The main source of successful psychotherapy is the client. The therapist’s
attention to the client’s frame of reference fosters the client’s utilization
of inner and outer resources.
Emotion-Focused Therapy
emotion-focused therapy (eFt) emerged as a person-centered “approach
informed by understanding the role of emotion in human functioning and psycho-
therapeutic change” (Greenberg, 2014, p. 15). Leslie Greenberg, a prominent figure
in the development of this integrative approach, states that EFT is designed to help
clients increase their awareness of their emotions and make productive use of them.
Like person-centered therapists, emotion-focused therapists establish a therapeutic
LO2
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168 C H A P T E R S E V E N
relationship based on the core therapeutic conditions. Once the therapeutic alliance
is created, however, the EFT practitioner actively works with emotions using a range
of experiential techniques to strengthen the self, regulate affect, and create new mean-
ing. New narratives can be created that disrupt maladaptive past emotional schemas,
which provides opportunities for positive emotional experiencing (McDonald, 2015).
EFT strategies focus on two major tasks: (1) help clients with too little emotion
access their emotions, and (2) help clients who experience too much emotion con-
tain their emotions (Greenberg, 2014). Many traditional therapies emphasize con-
scious understanding and cognitive and behavioral change, but they often neglect
the foundational role of emotional change. A main goal of EFT is to help individuals
access and process emotions to construct new ways of being. This approach has a
good deal to offer with respect to teaching us about the role of emotion in per-
sonal change and how emotional change can be a primary pathway to cognitive and
behavioral change (Greenberg, 2014).
EFT emphasizes the importance of awareness, acceptance, and understanding
the visceral experience of emotion. Greenberg (2014) believes that our emotions
cannot be change merely by talking about them, understanding their origins, or by
modifying our beliefs. Clients are encouraged to identify, experience, accept, express,
explore, transform, and manage their emotions. The act of experiencing feelings and
replacing old feelings with new positive feelings offers a corrective emotional expe-
rience. “One changes emotions by accepting and experiencing them, by opposing
them with different emotions to transform them, and by reflecting on them to cre-
ate new narrative meaning” (p. 18).
Both psychoanalytic and cognitive behavioral approaches are increasingly focus-
ing on emotions and are rapidly assimilating many aspects of EFT. Gestalt therapy
has always emphasized experiencing and exploring emotions. McDonald (2015)
reports that a strength of EFT is that it is an empirically validated brief therapeutic
approach with demonstrated effectiveness in treating anxiety, intimate partner vio-
lence, eating disorders, and trauma. EFT is being applied to counseling individuals,
groups, couples, families, and in working in diverse cultural contexts.
The theory and practice of EFT are only briefly discussed in this chapter. For an
in-depth discussion of the principles and techniques involved in the practice of EFT,
see Greenberg (2011), Emotion-Focused Therapy.
Existentialism and Humanism
In the 1960s and 1970s there was a growing interest among counselors in a “third
force” in therapy as an alternative to the psychoanalytic and behavioral approaches.
Under this heading fall existential therapy (Chapter 6), person-centered therapy
(Chapter 7), Gestalt therapy (Chapter 8), and certain other experiential and rela-
tionship-oriented approaches.
The connections between the terms existentialism and humanism have tended
to be confusing for students and theorists alike. The two viewpoints have much in
common, yet there also are significant philosophical differences between them. They
share a respect for the client’s subjective experience, the uniqueness and individual-
ity of each client, and a trust in the capacity of the client to make positive and con-
structive conscious choices. They have in common an emphasis on concepts such as
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P E R S o N – C E N T E R E d T H E R A P y 169
freedom, choice, values, personal responsibility, autonomy, purpose, and meaning.
Both approaches place little value on the role of techniques in the therapeutic pro-
cess and emphasize instead the importance of genuine encounter.
They differ in that existentialists take the position that we are faced with the
anxiety of choosing to create an identity in a world that lacks intrinsic meaning.
Existentialists tend to acknowledge the stark realities of human experience, and
their writings often focus on death, anxiety, meaninglessness, and isolation. The
humanists, in contrast, take the somewhat less anxiety-evoking and more optimistic
view that each of us has a natural potential that we can actualize and through which
we can find meaning. Many contemporary existential therapists refer to themselves
as existential-humanistic practitioners, indicating that their roots are in existential
philosophy but that they have incorporated many aspects of North American
humanistic psychotherapies (Cain, 2002a; Schneider & Krug, 2010).
As will become evident in this chapter, the existential and person-centered
approaches have parallel concepts with regard to the client–therapist relationship
being at the core of therapy. The phenomenological emphasis that is basic to the exis-
tentialist approach is also fundamental to person-centered theory. Both approaches
focus on the client’s perceptions and call for the therapist to be fully present with the
client so that it is possible to understand the client’s subjective world, and they both
emphasize the client’s capacity for self-awareness and self-healing. The therapist aims
to provide the client with a safe, responsive, and caring relationship to facilitate self-
exploration, growth, and healing (Watson, Goldman, & Greenberg, 2011).
Abraham Maslow’s Contributions to Humanistic Psychology
Abraham Maslow (1970) was a pioneer in the development of humanistic
psychology and was influential in furthering the understanding of self-actualizing
individuals. Many of Carl Rogers’s ideas, especially on the positive aspects of being
human and the fully functioning person, are influenced by Maslow’s basic philoso-
phy. Maslow criticized Freudian psychology for what he saw as its preoccupation
with the sick and dark side of human nature. Maslow believed too much research
was being conducted on anxiety, hostility, and neuroses and too little into joy, cre-
ativity, and self-fulfillment. Self-actualization was the central theme of the work
of Abraham Maslow (1968, 1970, 1971). The positive psychology movement that
recently has come into prominence shares many concepts on the healthy side of
human existence with the humanistic approach.
Maslow studied what he called “self-actualizing people” and found that they dif-
fered in important ways from so-called normal individuals. The core characteristics of
self-actualizing people are self-awareness, freedom, basic honesty and caring, and trust
and autonomy. Other characteristics of self-actualizing individuals include a capacity
to welcome uncertainty in their lives, acceptance of themselves and others, spontane-
ity and creativity, a need for privacy and solitude, autonomy, a capacity for deep and
intense interpersonal relationships, a genuine caring for others, an inner-directedness
(as opposed to the tendency to live by others’ expectations), the absence of artificial
dichotomies within themselves (such as work/play, love/hate, and weak/strong), and
a sense of humor (Maslow, 1970). All of these personal characteristics are compatible
with the person-centered philosophy.
LO3
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170 C H A P T E R S E V E N
Maslow postulated a hierarchy of needs as a source of motivation, with the most
basic needs being physiological needs. If we are hungry and thirsty, our attention is
riveted on meeting these basic needs. Next are the safety needs, which include a sense
of security and stability. Once our physical and safety needs are fulfilled, we become
concerned with meeting our needs for belonging and love, followed by our need for
esteem, both from self and others. We are able to strive toward self-actualization
only after these four basic needs are met. The key factor determining which need is
dominant at a given time is the degree to which those below it are satisfied.
The Vision of Humanistic Philosophy The underlying vision of humanistic
philosophy is captured by the metaphor of how an acorn, if provided with the
appropriate conditions, will “automatically” grow in positive ways, pushed
naturally toward its actualization as an oak. In contrast, for many existentialists
there is nothing that we “are,” no internal “nature” we can count on. We are faced
at every moment with a choice about what to make of this condition. Maslow’s
emphasis on the healthy side of being human and the emphasis on joy, creativity,
and self-fulfillment are part of the person-centered philosophy. The humanistic
philosophy on which the person-centered approach rests is expressed in attitudes
and behaviors that create a growth-producing climate. According to Rogers (1986b),
when this philosophy is lived, it helps people develop their capacities and stimulates
constructive change in others. Individuals are empowered, and they are able to use
this power for personal and social transformation.
Key Concepts
View of Human Nature
A common theme originating in Rogers’s early writing and continuing to permeate
all of his works is a basic sense of trust in the client’s ability to move forward in a
constructive manner if conditions fostering growth are present. His professional
experience taught him that if one is able to get to the core of an individual, one finds
a trustworthy, positive center (C. Rogers, 1987a). In keeping with the philosophy
of humanistic psychology, Rogers firmly maintained that people are trustworthy,
resourceful, capable of self-understanding and self-direction, able to make construc-
tive changes, and able to live effective and productive lives. When therapists are able
to experience and communicate their realness, support, caring, and nonjudgmental
understanding, significant changes in the client are most likely to occur.
Rogers maintained that three therapist attributes create a growth-promoting
climate in which individuals can move forward and become what they are capable
of becoming: (1) congruence (genuineness, or realness), (2) unconditional positive regard
(acceptance and caring), and (3) accurate empathic understanding (an ability to deeply
grasp the subjective world of another person). According to Rogers, if therapists
communicate these attitudes, those being helped will become less defensive and
more open to themselves and their world, and they will behave in prosocial and con-
structive ways.
The actualizing tendency is a directional process of striving toward realization,
fulfillment, autonomy, and self-determination. This natural inclination of humans
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P E R S o N – C E N T E R E d T H E R A P y 171
is based on Maslow’s (1970) studies of self-actualizing people, and it has significant
implications for the practice of therapy. Because of the belief that the individual has an
inherent capacity to move away from maladjustment and toward psychological health
and growth, the therapist places the primary responsibility on the client. The person-
centered approach rejects the role of the therapist as the authority who knows best
and of the passive client who depends on the therapist’s expertise. Therapy is rooted in
the client’s capacity for awareness and self-directed change in attitudes and behavior.
The person-centered approach emphasizes clients’ abilities to engage their own
resources to act in their world with others. Clients can move forward in constructive
directions and successfully deal with obstacles (both from within themselves and
outside of themselves) that are blocking their growth. By promoting self-awareness
and self-reflection, clients learn to exercise choice. Humanistic therapists emphasize
a discovery-oriented approach in which clients are the experts on their own inner
experience (Watson et al., 2011), and they encourage clients to make changes that
will lead to living fully and authentically, with the realization that this kind of exis-
tence demands a continuing struggle.
The Therapeutic Process
Therapeutic Goals
Rogers did not believe the goal of therapy was merely to solve problems. Rather, the
goal is to assist clients in achieving a greater degree of independence and integra-
tion so they can better cope with problems as they identify them. Before clients are
able to work toward that goal, they must first get behind the masks they wear, which
they develop through the process of socialization. Clients come to recognize that
they have lost contact with themselves by using facades. In a climate of safety in the
therapeutic session, they also come to realize that there are more authentic ways of
being. The therapist does not choose specific goals for the client. The cornerstone
of person-centered theory is the view that clients in a relationship with a facilitating
therapist have the capacity to define and clarify their own goals. Person-centered
therapists are in agreement on the matter of not setting goals for what clients need
to change, yet they differ on the matter of how to best help clients achieve their own
goals and to find their own answers (Bohart & Watson, 2011).
Therapist’s Function and Role
The role of person-centered therapists is rooted in their ways of being and
attitudes, not in techniques designed to get the client to “do something.” Research
on person-centered therapy indicates that the attitude of therapists, rather than
their knowledge, theories, or techniques, facilitate personality change in clients
(C. Rogers, 1961). Basically, therapists use themselves as an instrument of change by
encountering clients on a person-to-person level. In examining the human elements
of psychotherapy, Elkins (2016) concludes that the human dimensions are more
powerful determinants of therapeutic effectiveness than theories or techniques. It is
the therapist’s attitude and belief in the inner resources of the client that creates the
therapeutic climate for growth (Bozarth et al., 2002).
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172 C H A P T E R S E V E N
Person-centered theory holds that the therapist’s function is to be present and
accessible to clients and to focus on their immediate experience. First and foremost,
the therapist must be willing to be real in the relationship with clients. By being
congruent, accepting, and empathic, the therapist is a catalyst for change. Instead of
viewing clients in preconceived diagnostic categories, the therapist meets them on
a moment-to-moment experiential basis and enters their world. Through the thera-
pist’s attitude of genuine caring, respect, acceptance, support, and understanding,
clients are able to loosen their defenses and rigid perceptions and move to a higher
level of personal functioning. When these therapist attitudes are present, clients
then have the necessary freedom to explore areas of their life that were either denied
to awareness or distorted.
Client’s Experience in Therapy
Therapeutic change depends on clients’ perceptions both of their own experience
in therapy and of the counselor’s basic attitudes. If the counselor creates a climate
conducive to self-exploration, clients have the opportunity to explore the full range
of their experience, which includes their feelings, beliefs, behavior, and worldview.
What follows is a general sketch of clients’ experiences in therapy.
Clients come to the counselor in a state of incongruence; that is, a discrepancy
exists between their self-perception and their experience in reality. For example, Leon,
a college student, may see himself as a future physician, yet his below-average grades
could exclude him from medical school. The discrepancy between how Leon sees
himself (self-concept) or how he would like to view himself (ideal self-concept) and
the reality of his poor academic performance may result in anxiety and personal vul-
nerability, which can provide the necessary motivation to enter therapy. Leon must
perceive that a problem exists or, at least, that he is uncomfortable enough with his
present psychological adjustment to want to explore possibilities for change.
One reason clients seek therapy is a feeling of basic helplessness, powerlessness,
and an inability to make decisions or effectively direct their own lives. They may
hope to find “the way” through the guidance of the therapist. Within the person-
centered framework, however, clients soon learn that they can be responsible for
themselves in the relationship and that they can learn to be more free by using the
relationship to gain greater self-understanding.
As counseling progresses, clients are able to explore a wider range of beliefs and
feelings. They can express their fears, anxiety, guilt, shame, hatred, anger, and other
emotions that they had deemed too negative to accept and incorporate into their
self-structure. With therapy, people distort less and move to a greater acceptance
and integration of conflicting and confusing feelings. They increasingly discover
aspects within themselves that had been kept hidden. As clients feel understood
and accepted, they become less defensive and become more open to their experience.
Because they feel safer and are less vulnerable, they become more realistic, perceive
others with greater accuracy, and become better able to understand and accept oth-
ers. Individuals in therapy come to appreciate themselves more as they are, and their
behavior shows more flexibility and creativity. They become less concerned about
meeting others’ expectations, and thus begin to behave in ways that are truer to
themselves. These individuals direct their own lives instead of looking outside of
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P E R S o N – C E N T E R E d T H E R A P y 173
themselves for answers. They move in the direction of being more in contact with
what they are experiencing at the present moment, less bound by the past, less deter-
mined, freer to make decisions, and increasingly trusting in themselves to manage
their own lives. In short, their experience in therapy is like throwing off the self-
imposed shackles that had kept them in a psychological prison. With increased free-
dom, they tend to become more mature psychologically and move toward increased
self-actualization.
Person-centered therapy is grounded on the assumption that clients create their
own self-growth and are active self-healers (Bohart & Tallman, 1999, 2010; Bohart &
Wade, 2013; Bohart & Watson, 2011). The therapy relationship provides a support-
ive structure within which clients’ self-healing capacities are activated. What clients
value most is being understood and accepted, which results in creating a safe place
to explore feelings, thoughts, behaviors, and experiences; clients also value support
for trying out new behaviors (Bohart & Tallman, 2010).
Relationship Between Therapist and Client
Rogers (1957) based his hypothesis of the “necessary and sufficient condi-
tions for therapeutic personality change” on the quality of the relationship: “If I can
provide a certain type of relationship, the other person will discover within himself
or herself the capacity to use that relationship for growth and change, and personal
development will occur” (C. Rogers, 1961, p. 33). Rogers (1967) hypothesized fur-
ther that “significant positive personality change does not occur except in a rela-
tionship” (p. 73). Rogers’s hypothesis was formulated on the basis of many years of
his professional experience, and it remains basically unchanged to this day.
1. Two persons are in psychological contact.
2. The first, whom we shall term the client, is in a state of incongruence,
being vulnerable or anxious.
3. The second person, whom we term the therapist, is congruent (real or
genuine) in the relationship, and this congruence is perceived by the
client.
4. The therapist experiences unconditional positive regard for the
client.
5. The therapist experiences an empathic understanding of the client’s
internal frame of reference and endeavors to communicate this experi-
ence to the client.
6. The communication to the client of the therapist’s empathic under-
standing and unconditional positive regard is to a minimal degree
achieved. (as cited in Cain 2002a, p. 20)
Rogers hypothesized that no other conditions were necessary. If the therapeutic
core conditions exist over some period of time, constructive personality change
will occur. The core conditions do not vary according to client type. Further, they
are both necessary and sufficient for therapeutic change to occur.
From Rogers’s perspective, the client–therapist relationship is characterized by
equality. Therapists do not keep their knowledge a secret or attempt to mystify the
therapeutic process. The process of change in the client depends to a large degree
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174 C H A P T E R S E V E N
on the quality of this equal relationship. As clients experience the therapist listen-
ing in an accepting way to them, they gradually learn how to listen acceptingly to
themselves. As they find the therapist caring for and valuing them (even the aspects
that have been hidden and regarded as negative), clients begin to develop worth and
value in themselves. As they experience the realness of the therapist, clients drop
many of their pretenses and become real with both themselves and the therapist.
This humanistic approach is perhaps best characterized as a way of being and as a
shared journey in which therapist and client reveal their humanness and participate in
a growth experience. The therapist can be a relational guide on this journey because
he or she is usually more psychologically experienced in this role than the client.
Therapists are invested in broadening their own life experiences and are willing to
do what it takes to deepen their self-knowledge.
Rogers admitted that his theory was strikingly provocative and radical. His for-
mulation has generated considerable controversy, for he maintained that many con-
ditions other therapists commonly regard as necessary for effective psychotherapy
were nonessential. The core therapist conditions of congruence, unconditional posi-
tive regard, and accurate empathic understanding subsequently have been embraced
by many therapeutic schools as essential in facilitating therapeutic change. These
core qualities of therapists, along with the therapist’s presence, work holistically to
create a safe environment for learning (Cain, 2010). Regardless of theoretical orien-
tation, most therapists strive to listen fully and empathically to clients, especially
during the initial stages of therapy. We now turn to a detailed discussion of how
these core conditions are an integral part of the therapeutic relationship.
Congruence, or Genuineness congruence implies that therapists are real; that
is, they are genuine, integrated, and authentic during the therapy hour. They are
without a false front, their inner experience and outer expression of that experience
match, and they can openly express feelings, thoughts, reactions, and attitudes that
are present in the relationship with the client. This communication is done with
careful reflection and considered judgment on the therapist’s part (Kolden, Klein,
Wang, & Austin, 2011).
Through authenticity the therapist serves as a model of a human being strug-
gling toward greater realness. Being congruent might necessitate expressing a
range of feelings including anger, frustration, liking, concern, and annoyance. This
does not mean that therapists should impulsively share all their reactions, for self-
disclosure must be appropriate, well timed, and have a constructive therapeutic
intent. Counselors can try too hard to be genuine; sharing because they think it
will be good for the client, without being genuinely moved to express something
regarded as personal, can be incongruent. Person-centered therapy stresses that
counseling will be inhibited if the counselor feels one way about the client but acts
in a different way. For example, if the practitioner dislikes or disapproves of the cli-
ent but feigns acceptance, therapy will be impaired. Cain (2010) stresses that thera-
pists need to be attuned to the emerging needs of the client and to respond in ways
that are in the best interests of the individual. If therapists keep this in mind, they
are likely to make sound therapeutic decisions most of the time.
Rogers’s concept of congruence does not imply that only a fully self-actualized
therapist can be effective in counseling. Because therapists are human, they cannot
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P E R S o N – C E N T E R E d T H E R A P y 175
be expected to be fully authentic. Congruence exists on a continuum from highly
congruent to very incongruent. This is true of all three characteristics.
Unconditional Positive Regard and Acceptance The second attitude therapists
need to communicate is deep and genuine caring for the client as a person.
Unconditional positive regard can best be achieved through empathic identifica-
tion with the client (Farber & Doolin, 2011). The caring is nonpossessive and is
not contaminated by evaluation or judgment of the client’s feelings, thoughts,
and behavior as good or bad. Therapists value and warmly accept clients without
placing stipulations on their acceptance. It is not an attitude of “I’ll accept you
when . . . ”; rather, it is one of “I’ll accept you as you are.” Therapists communicate
through their behavior that they value their clients as they are and that clients are
free to have feelings and experiences.
According to Rogers’s (1977) research, the greater the degree of caring, prizing,
accepting, and valuing of the client in a nonpossessive way, the greater the chance
that therapy will be successful. He also makes it clear that it is not possible for thera-
pists to genuinely feel acceptance and unconditional caring at all times. However, if
therapists have little respect for their clients, or an active dislike or disgust, it is not
likely that the therapeutic work will be fruitful. If therapists’ caring stems from their
own need to be liked and appreciated, constructive change in the client is inhibited.
This notion of positive regard has implications for all therapists, regardless of their
theoretical orientation (Farber & Doolin, 2011).
Accurate Empathic Understanding One of the main tasks of the therapist is
to understand clients’ experience and feelings sensitively and accurately as they
are revealed in the moment-to-moment interaction during the therapy session.
The therapist strives to sense clients’ subjective experience, particularly in the here
and now. The aim is to encourage clients to get closer to themselves, to feel more
deeply and intensely, and to recognize and resolve the incongruity that exists
within them.
empathy is a deep and subjective understanding of the client with the client.
Empathy is not sympathy, or feeling sorry for a client. Therapists are able to share
the client’s subjective world by drawing from their own experiences that may be
similar to the client’s feelings. Yet therapists must not lose their own separateness.
Rogers asserts that when therapists can grasp the client’s private world as the client
sees and feels it—without losing the separateness of their own identity—constructive
change is likely to occur. Empathy, particularly emotionally focused empathy, helps
clients (1) pay attention to and value their experiencing, (2) process their experience
both cognitively and bodily, (3) view prior experiences in new ways, and (4) increase
their confidence in making choices and in pursuing a course of action (Cain, 2010).
Clark (2010) describes an integral model of empathy in the counseling process
that is based on three ways of knowing: (1) subjective empathy enables practitioners to
experience what it is like to be the client; (2) interpersonal empathy pertains to under-
standing a client’s internal frame of reference and conveying a sense of the private
meanings to the person; and (3) objective empathy relies on knowledge sources outside
of a client’s frame of reference. By using a multiple-perspective model of empathy,
counselors have a broader way to understand clients.
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176 C H A P T E R S E V E N
Accurate empathy is the cornerstone of the person-centered approach, and it
is a necessary ingredient of any effective therapy (Cain, 2010). accurate empathic
understanding implies that the therapist will sense clients’ feelings as if they were
his or her own without becoming lost in those feelings. It is a way for therapists to
hear the meanings expressed by their clients that often lie at the edge of their aware-
ness. A primary means of determining whether an individual experiences a thera-
pist’s empathy is to secure feedback from the client (Norcross, 2010).
According to Watson (2002), full empathy entails understanding the meaning
and feeling of a client’s experiencing. It is like grasping “what it is like to be you.”
Empathy is an active ingredient of change that facilitates clients’ cognitive processes
and emotional self-regulation. Watson’s comprehensive review of the research litera-
ture on therapeutic empathy has consistently demonstrated that therapist empathy
is the most potent predictor of client progress in therapy. Empathy is an essential
component of successful therapy in every therapeutic modality.
Clients’ perceptions of feeling understood by their therapists relate favorably to
outcome. Empathic therapists strive to discover the meaning of the client’s experi-
ence, understand the overall goals of the client, and tailor their responses to the
particular client. Effective empathy is grounded in authentic caring for the client
(Elliott, Bohart, Watson, & Greenberg, 2011).
Application: Therapeutic Techniques and Procedures
Early Emphasis on Reflection of Feelings
Rogers’s original emphasis was on grasping the world of the client and reflecting
this understanding. As his view of psychotherapy developed, however, his focus
shifted away from an absolutist, nondirective stance and emphasized the therapist’s
relationship with the client. Many followers of Rogers simply imitated his reflec-
tive style, and client-centered therapy has often been identified primarily with the
technique of reflection despite Rogers’s contention that the therapist’s relational
attitudes and fundamental ways of being with the client constitute the heart of the
change process. Rogers and other contributors to the development of the person-
centered approach have been critical of the stereotypic view that this approach is
basically a simple restatement of what the client just said.
Evolution of Person-Centered Methods
Contemporary person-centered therapy is the result of an evolutionary pro-
cess of more than 70 years, and it continues to remain open to change and refine-
ment. One of Rogers’s main contributions to the counseling field is the notion that
the quality of the therapeutic relationship, as opposed to administering techniques,
is the primary agent of growth in the client. The therapist’s ability to establish a
strong connection with clients is the critical factor determining successful counsel-
ing outcomes.
No techniques are basic to the practice of person-centered therapy; “being with”
clients and entering imaginatively into their world of perceptions and feelings is
sufficient for facilitating a process of change. Person-centered therapists are not
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P E R S o N – C E N T E R E d T H E R A P y 177
prohibited from suggesting techniques, but how these suggestions are presented is
crucial. Some clients do better with more direction, whereas others do better in a
nondirective climate (Cain, 2010). What is essential for clients’ progress is the thera-
pist’s presence—being completely attentive to and immersed in the client as well as
in the client’s expressed concerns (Cain, 2010). Qualities and skills such as listening,
accepting, respecting, understanding, and responding must be honest expressions
by the therapist. Techniques may be suggested when doing so fosters the process of
client and therapist being together in an empathic way. Techniques are not attempts
at “doing anything” to a client (Bohart & Watson, 2011).
Rogers expected person-centered therapy to continue to evolve and supported
others in breaking new ground. One of the main ways in which person-centered
therapy has evolved is the diversity, innovation, and individualization in practice.
There is no longer one way of practicing person-centered therapy (Cain, 2010), and
there has been increased latitude for therapists to share their reactions, to confront
clients in a caring way, and to participate more actively and fully in the therapeutic
process (Bozarth et al., 2002). immediacy, or addressing what is going on between
the client and therapist, is highly valued in this approach. This development encour-
ages the use of a wider variety of methods and allows for considerable diversity in
personal style among person-centered therapists. The shift toward genuineness
enables person-centered therapists both to practice in more flexible and integrative
ways that suit their personalities and to have greater flexibility in tailoring the coun-
seling relationship to suit different clients (Bohart & Watson, 2011).
Cain (2010, 2013) believes it is essential for therapists to adapt their therapeutic
style to accommodate the unique needs of each client. Person-centered therapists
have the freedom to use a variety of responses and methods to assist their clients;
a guiding question therapists need to ask is, “Does it fit?” Cain contends that, ide-
ally, therapists will continually monitor whether what they are doing fits, especially
whether their therapeutic style is compatible with their clients’ way of viewing and
understanding their problems. For an illustration of how Dr. David Cain works
with the case of Ruth in a person-centered style, see Case Approach to Counseling and
Psychotherapy (Corey, 2013, chap. 5).
Today, those who practice a person-centered approach work in diverse ways that
reflect both advances in theory and practice and a plethora of personal styles. This is
appropriate and fortunate, for none of us can emulate the style of Carl Rogers and
still be true to ourselves. If we strive to model our style after Rogers, and if that style
does not fit for us, we are not being ourselves and we are not being fully congruent.
The Role of Assessment
Assessment is frequently viewed as a prerequisite to the treatment process. Many
mental health agencies use a variety of assessment procedures, including diagnostic
screening, identification of clients’ strengths and liabilities, and various tests. Person-
centered therapists generally do not find traditional assessment and diagnosis to be
useful because these procedures encourage an external and expert perspective on the
client (Bohart & Watson, 2011). What matters is not how the counselor assesses the
client but the client’s self-assessment. From a person-centered perspective, the best
source of knowledge about the client is the individual client. Rogers saw therapy as
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178 C H A P T E R S E V E N
co-assessment, whereby the therapist and the client engage in a continuous process
of self-understanding.
Assessment seems to be gaining in importance in short-term treatments in most
counseling agencies, and it is imperative that clients be involved in a collaborative
process in making decisions that are central to their therapy. Today it may not be a
question of whether to incorporate assessment into therapeutic practice but of how
to involve clients as fully as possible in their assessment and treatment process.
Application of the Philosophy of the Person-Centered Approach
The person-centered approach has been applied to working with individuals, groups,
and families. Bozrath, Zimring, and Tausch (2002) cite studies done through the
1990s that revealed the effectiveness of person-centered therapy with a wide range
of client problems including anxiety disorders, alcoholism, psychosomatic prob-
lems, agoraphobia, interpersonal difficulties, depression, cancer, and personality
disorders. Person-centered therapy has been shown to be as viable as the more goal-
oriented therapies. Furthermore, outcome research conducted in the 1990s revealed
that effective therapy is based on the client–therapist relationship in combination
with the inner and external resources of the client (Duncan, Miller, Wampold, &
Hubble, 2010).
The person-centered approach has been applied extensively in training both pro-
fessionals and paraprofessionals who work with people in a variety of settings. This
approach emphasizes staying with clients as opposed to getting ahead of them with
interpretations. People without advanced psychological education are able to ben-
efit by translating the therapeutic conditions of genuineness, empathic understand-
ing, and unconditional positive regard into both their personal and professional
lives. Learning to listen to oneself with acceptance is a valuable life skill that enables
individuals to be their own therapists. The basic concepts are straightforward and
easy to comprehend, and they encourage locating power in the person rather than
fostering an authoritarian structure in which control and power are denied to the
person. These core skills also provide an essential foundation for virtually all of the
other therapy systems covered in this book. If counselors are lacking in these rela-
tionship and communication skills, they will not be effective in carrying out a treat-
ment program for their clients.
The person-centered approach demands a great deal of the therapist. An effective
person-centered therapist must be an astute listener who is grounded, centered, gen-
uine, respectful, caring, present, focused, patient, and accepting in a way that involves
maturity. Without a person-centered way of being, mere application of skills is likely
to be hollow. Natalie Rogers (2011) points out that the person-centered approach is
a way of being that is easy to understand intellectually but is very difficult to put into
practice. She continues to find the core conditions of genuineness, positive regard,
and empathy most important in developing trust, safety, and growth in a group.
Application to Crisis Intervention
The person-centered approach is especially applicable in crisis intervention
such as an unwanted pregnancy, an illness, a disastrous event, or the loss of a loved
one. People in the helping professions (nursing, medicine, education, the ministry)
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P E R S o N – C E N T E R E d T H E R A P y 179
are often first on the scene in a variety of crises, and they can do much if the basic
attitudes described in this chapter are present. When people are in crisis, one of
the first steps is to give them an opportunity to fully express themselves. Sensitive
listening, hearing, and understanding are essential at this point. Being heard and
understood helps ground people in crises, helps to calm them in the midst of tur-
moil, and enables them to think more clearly and make better decisions. Although
a person’s crisis is not likely to be resolved by one or two contacts with a helper,
such contacts can pave the way for being open to receiving help later. If the person
in crisis does not feel understood and accepted, he or she may lose hope of “return-
ing to normal” and may not seek help in the future. Genuine support, caring, and
nonpossessive warmth can go a long way in building bridges that can motivate
people to do something to work through and resolve a crisis. Communicating a
deep sense of understanding should always precede other more problem-solving
interventions.
In crisis situations person-centered therapists may need to provide more struc-
ture and direction than would be the case for clients who are not experiencing a cri-
sis. Suggestions, guidance, and even direction may be called for if clients are not able
to function effectively. For example, it may be necessary to take action to hospitalize
a suicidal client to protect this person from self-harm.
Application to Group Counseling
The person-centered approach emphasizes the unique role of the group counselor
as a facilitator rather than a leader. The primary function of the facilitator is to
create a safe and healing climate—a place where the group members can interact in
honest and meaningful ways. In this climate members become more appreciative
and trusting of themselves as they are and are able to move toward self-direction
and empowerment. The facilitator’s way of being can create a productive climate
within a group:
Facilitators cannot make participants trust the group process. Facilitators earn
trust by being respectful, caring, and even loving. Being an effective group facilita-
tor has much to do with one’s “way of being.” No method or technique can evoke
trust unless the facilitator herself has a capacity to be fully present, considerate,
caring, authentic, and responsive. This includes the ability to challenge people
constructively. (N. Rogers, 2011, p. 57)
With the presence of the facilitator and the support of other members, participants
realize that they do not have to experience the struggles of change alone and that
groups as collective entities have their own source of transformation.
Carl Rogers (1970) clearly believed that groups tend to move forward if the
facilitator exhibits a deep sense of trust in the members and refrains from using
techniques or exercises to get a group moving. Facilitators should avoid making
interpretive comments or group process observations because such comments are
apt to make the group self-conscious and slow the process down. Group process
observations should come from members, a view that is consistent with Rogers’s
philosophy of placing the responsibility for the direction of the group on the mem-
bers. Instead of leading the members toward specific goals, the group facilitator
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180 C H A P T E R S E V E N
assists members in developing attitudes and behaviors of genuineness, acceptance,
and empathy, which enables the members to interact with each other in therapeutic
ways to find their own sense of direction as a group.
Regardless of a group leader’s theoretical orientation, the core conditions that
have been described here are highly applicable to any leader’s style of group facilita-
tion. Only when the leader is able to create a person-centered climate will movement
take place within a group. All of the theories discussed in this book depend on the
quality of the therapeutic relationship as a foundation. As you will see, the cognitive
behavioral approaches to group work also emphasize creating a working alliance
and collaborative relationships. Indeed, most effective approaches to group work
share key elements of a person-centered philosophy. For a more detailed treatment
of person-centered group counseling, see Corey (2016, chap. 10). Also see Natalie
Rogers’s book (2011), The Creative Connection for Groups: Person-Centered Expressive Arts
for Healing and Social Change.
Person-Centered Expressive Arts Therapy*
Natalie Rogers (1993, 2011) expanded on her father’s (C. Rogers, 1961) the-
ory of creativity using the expressive arts to enhance personal growth for individuals
and groups. N. Rogers’s approach, known as expressive arts therapy, extends the
person-centered approach to spontaneous creative expression, which symbolizes
deep and sometimes inaccessible feelings and emotional states. Counselors trained
in person-centered expressive arts offer their clients the opportunity to create move-
ment, visual art, journal writing, sound, and music to express their feelings and gain
insight from these activities.
Principles of Expressive Arts Therapy
Expressive arts therapy uses various artistic forms—movement, drawing, painting,
sculpting, music, writing, and improvisation—toward the end of growth, healing,
and self-discovery. This is a multimodal approach integrating mind, body, emo-
tions, and inner spiritual resources. Methods of expressive arts therapy are based
on humanistic principles but give fuller form to Carl Rogers’s notions of creativity.
These principles include the following (N. Rogers, 1993):
�� All people have an innate ability to be creative.
�� The creative process is transformative and healing. The healing aspects
involve activities such as meditation, movement, art, music, and journal
writing.
�� Personal growth and higher states of consciousness are achieved
through self-awareness, self-understanding, and insight.
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*Much of the material in this section is based on key ideas that are more fully developed in The Creative
Connection: Expressive Arts as Healing (N. Rogers, 1993) and The Creative Connection for Groups: Person-Centered
Expressive Arts for Healing and Social Change (N. Rogers, 2011). This section was written in close collaboration
with Natalie Rogers.
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P E R S o N – C E N T E R E d T H E R A P y 181
�� Self-awareness, understanding, and insight are achieved by delving into
our feelings of grief, anger, pain, fear, joy, and ecstasy.
�� Our feelings and emotions are an energy source that can be channeled
into the expressive arts to be released and transformed.
�� The expressive arts lead us into the unconscious, thereby enabling us to
express previously unknown facets of ourselves and bring to light new
information and awareness.
�� One art form stimulates and nurtures the other, bringing us to an inner
core or essence that is our life energy.
�� A connection exists between our life force—our inner core, or soul—and
the essence of all beings.
�� As we journey inward to discover our essence or wholeness, we discover
our relatedness to the outer world, and the inner and outer become one.
The various art modes interrelate in what Natalie Rogers calls the “creative connec-
tion.” When we move, it affects how we write or paint. When we write or paint, it
affects how we feel and think.
Natalie Rogers’s approach is based on a person-centered theory of individual
and group process. The same conditions that Carl Rogers and his colleagues found
basic to fostering a facilitative client–counselor relationship also help support cre-
ativity. Personal growth takes place in a safe, supportive environment created by
counselors or facilitators who are genuine, warm, empathic, open, honest, congru-
ent, and caring—qualities that are best learned by first being experienced. Taking
time to reflect on and evaluate these experiences allows for personal integration at
many levels—intellectual, emotional, physical, and spiritual.
Creativity and Offering Stimulating Experiences
According to Natalie Rogers, this deep faith in the individual’s innate drive to
become fully oneself is basic to the work in person-centered expressive arts. Indi-
viduals have a tremendous capacity for self-healing through creativity if given the
proper environment. When one feels appreciated, trusted, and given support to use
individuality to develop a plan, create a project, write a paper, or to be authentic, the
challenge is exciting, stimulating, and gives a sense of personal expansion. N. Rogers
believes the tendency to actualize and become one’s full potential, including innate
creativity, is undervalued, discounted, and frequently squashed in our society. Tra-
ditional educational institutions tend to promote conformity rather than original
thinking and the creative process.
Person-centered expressive arts therapy utilizes the arts for spontaneous cre-
ative expression that symbolizes deep and sometimes inaccessible feelings and
emotional states. The conditions that foster creativity require acceptance of the
individual, a nonjudgmental setting, empathy, psychological freedom, and avail-
ability of stimulating and challenging experiences. With this type of environment
in place, the facilitative internal conditions of the client are encouraged and
inspired. The client experiences a nondefensive openness and an internal locus of
evaluation that receives but is not overly concerned with the reactions of others.
N. Rogers (1993) believes that we cheat ourselves out of a fulfilling and joyous source
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182 C H A P T E R S E V E N
of creativity if we cling to the idea that an artist is the only one who can enter the
realm of creativity. Art is not only for the few who develop a talent or master a
medium. We all can use various art forms to facilitate self-expression and personal
growth.
Motivational Interviewing
Motivational interviewing (Mi) is a humanistic, client-centered, psycho-
social, and modestly directive counseling approach developed by William R. Miller
and Stephen Rollnick in the early 1980s. The clinical and research applications of
this evidenced-based practice have received increased attention in recent years, and
MI has been shown to be effective as a relatively brief intervention (Corbett, 2016;
Dean, 2015). Motivational interviewing is based on humanistic principles, has many
basic similarities with person-centered therapy, and expands the traditional person-
centered approach.
Motivational interviewing was initially designed as a brief intervention for prob-
lem drinking, but more recently this approach has been applied to a wide range of
clinical problems including substance abuse, compulsive gambling, eating disorders,
anxiety disorders, depression, suicidality, chronic disease management, and health
behavior change practices (Arkowitz & Miller, 2008; Arkowitz & Westra, 2009). MI
stresses client self-responsibility and promotes an invitational style for working
cooperatively with clients to generate alternative solutions to behavioral problems.
MI provides multiple ways to address the impasses clients often experience during
the change process. Both MI and person-centered practitioners believe in the client’s
abilities, strengths, resources, and competencies. The underlying assumption is that
clients want to be healthy and desire positive change.
The MI Spirit
MI is rooted in the philosophy of person-centered therapy, but with a “twist.” Unlike
the nondirective and unstructured person-centered approach, MI is deliberately
directive while staying within the client’s frame of reference. The primary goal is to
reduce client ambivalence about change and increase the client’s own motivation
for change. Miller and Rollnick (2013) believe that “MI is about arranging conver-
sations so that people talk themselves into change, based on their own values and
interests” (p. 4). It is essential that therapists function within the spirit of MI—that
is, within the relational context of therapy—rather than simply applying the strate-
gies of the approach. The attitudes and skills in MI are based on a person-centered
philosophy and include using open-ended questions, employing reflective listening,
creating a safe climate, affirming and supporting the client, expressing empathy,
responding to resistance in a nonconfrontational manner, guiding a discussion of
ambivalence, summarizing and linking at the end of sessions, and eliciting and rein-
forcing “change talk” (Dean, 2015). MI therapists avoid arguing with clients and
reframe resistance as a healthy response. MI therapists do not view clients as oppo-
nents to be defeated but as allies who play a major role in their present and future
success. Practitioners assist clients in becoming their own advocates for change and
the primary agents of change in their lives.
LO9
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P E R S o N – C E N T E R E d T H E R A P y 183
In both person-centered therapy and MI, the counselor provides the condi-
tions for growth and change by communicating attitudes of accurate empathy and
unconditional positive regard. In MI, the therapeutic relationship is as important
in achieving successful outcomes as the specific theoretical model or school of psy-
chotherapy from which the therapist operates (Miller & Rollnick, 2013). Both MI
and person-centered therapy are based on the premise that individuals have within
themselves the capacity to generate an intrinsic motivation to change. Responsibil-
ity for change rests with clients, not with the counselor, and therapist and client
share a sense of hope and optimism that change is possible. Once clients believe that
they have the capacity to change and heal, new possibilities open up for them.
The Basic Principles of Motivational Interviewing
Miller and Rollnick (2013) formulated five basic principles of MI:
1. Therapists strive to experience the world from the client’s perspec-
tive without judgment or criticism. MI emphasizes reflective listening,
which is a way for practitioners to better understand the subjective
world of clients. Expressing empathy is foundational in creating a safe
climate for clients to explore their ambivalence for change. When cli-
ents are slow to change, they likely have compelling reasons to remain
as they are as well as having reasons to change.
2. MI is designed to evoke and explore both discrepancies and ambiva-
lence. Counselors reflect discrepancies between the behaviors and
values of clients to increase the motivation to change. Counselors pay
particular attention to clients’ arguments for changing compared
to their arguments for not changing. Therapists elicit and reinforce
change talk by employing specific strategies to strengthen discus-
sion about change. Clinicians encourage clients to determine whether
change will occur, and if so, what kinds of changes will occur and
when.
3. Reluctance to change is viewed as an expected part of the therapeu-
tic process. Although individuals may see advantages to making life
changes, they also may have many concerns and fears about changing.
People who seek therapy are often ambivalent about change, and their
motivation may ebb and flow during the course of therapy. MI thera-
pists assume a respectful view of resistance and work therapeutically
with any reluctance or caution on the part of clients. MI practitioners
avoid disagreeing with, arguing with, or persuading clients because this
only entrenches resistance. Instead, therapists roll with the resistance,
which tends to reduce clients’ defensiveness (Corbett, 2016).
4. Practitioners support clients’ self-efficacy, mainly by encouraging them
to use their own resources to take necessary actions that can lead to
success in changing. MI clinicians strive to enhance client agency about
change and emphasize the right and inherent ability of clients to for-
mulate their own personal goals and to make their own decisions. MI
focuses on present and future conditions and empowers clients to find
ways to achieve their goals.
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184 C H A P T E R S E V E N
5. When clients show signs of readiness to change through decreased
resistance to change and increased talk about change, a critical phase
of MI begins. In this stage, clients may express a desire and ability
to change, show an interest in questions about change, experiment
with making changes between sessions, and envision a future picture
of how their life will be different once the desired changes have been
made. At this time therapists shift their focus toward strengthen-
ing clients’ commitments to change and helping them implement a
change plan.
The Stages of Change
The stages of change model assumes that people progress through a series of five
identifiable stages in the counseling process. In the precontemplation stage, there is
no intention of changing a behavior pattern in the near future. In the contemplation
stage, people are aware of a problem and are considering overcoming it, but they
have not yet made a commitment to take action to bring about the change. In the
preparation stage, individuals intend to take action immediately and report some
small behavioral changes. In the action stage, individuals are taking steps to modify
their behavior to solve their problems. During the maintenance stage, people work to
consolidate their gains and prevent relapse.
People do not pass neatly through these five stages in linear fashion, and a
client’s readiness can fluctuate throughout the change process. If change is ini-
tially unsuccessful, individuals may return to an earlier stage (Prochaska &
Norcross, 2014). MI therapists strive to match specific interventions with whatever
stage of change clients are experiencing. If there is a mismatch between process
and stage, movement through the stage will be impeded and is likely to be mani-
fested in reluctant behavior. When clients demonstrate any form of reluctance or
resistance, this could be due to a therapist’s misjudgment of a client’s readiness
to change.
Motivational interviewing is but one example of how therapeutic strategies
have been developed based on the foundational principles and philosophy of the
person-centered approach. Indeed, most of the therapeutic models illustrate how
the core therapeutic conditions are necessary aspects leading to client change.
Where many therapeutic approaches, including motivational interviewing, diverge
from traditional person-centered therapy is the assumption that the therapeutic
factors are both necessary and sufficient in bringing about change. Many other mod-
els employ specific intervention strategies to address specific concerns clients bring
to therapy.
Person-Centered Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
One of the strengths of the person-centered approach is its impact on the
field of human relations with diverse cultural groups. Person-centered philosophy
and practice can now be studied in several European countries, South America,
LO10
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P E R S o N – C E N T E R E d T H E R A P y 185
and Japan. Here are some examples of ways in which this approach has been incor-
porated in various countries and cultures:
�� In several European countries person-centered concepts have had a sig-
nificant impact on the practice of counseling as well as on education,
cross-cultural communication, and reduction of racial and political
tensions. In the 1980s Carl Rogers (1987b) elaborated on a theory of
reducing tension among antagonistic groups that he began developing
in 1948.
�� In the 1970s Rogers and his associates began conducting workshops
promoting cross-cultural communication. Well into the 1980s he led
large workshops in many parts of the world. International encounter
groups have provided participants with multicultural experiences.
�� Japan, Australia, South America, Mexico, and the United Kingdom have
all been receptive to person-centered concepts and have adapted these
practices to fit their cultures.
�� Shortly before his death, Rogers conducted intensive workshops with
professionals in the former Soviet Union.
There is no doubt that Carl Rogers has had a global impact. His work has reached
more than 30 countries, and his writings have been translated into 12 languages. The
emphasis on core conditions makes the person-centered approach useful in under-
standing diverse worldviews. The underlying philosophy of person-centered therapy
is grounded on the importance of hearing the deeper messages of a client. Empathy,
being present, and respecting the values of clients are essential attitudes and skills in
counseling culturally diverse clients. Although person-centered therapists are aware
of diversity factors, they do not make initial assumptions about individuals (Cain,
2010, 2013). Therapists realize that each client’s journey is unique and take steps to
tailor their methods to fit the individual.
Several writers consider person-centered therapy as being ideally suited to clients
in a diverse world. Bohart and Watson (2011) claim that the person-centered philos-
ophy is particularly appropriate for working with diverse client populations because
the counselor does not assume the role of expert who is going to impose a “right
way of being” on the client. Instead, the therapist is a “fellow explorer” who attempts
to understand the client’s phenomenological world in an interested, accepting, and
open way and checks with the client to confirm that the therapist’s perceptions are
accurate. Motivational interviewing, which is based on the philosophy of person-
centered therapy, is a culturally sensitive approach that can be effective across popu-
lation domains, including gender, age, ethnicity, and sexual orientation (Levensky,
Kersh, Cavasos, & Brooks, 2008).
Shortcomings From a Diversity Perspective
Although the person-centered approach has made significant contributions to
counseling people from diverse social, political, and cultural backgrounds, there
are some shortcomings to practicing exclusively within this framework. Many cli-
ents who come to community mental health clinics or who are involved in outpa-
tient treatment want more structure than this approach provides. Some clients seek
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186 C H A P T E R S E V E N
professional help to deal with a crisis, to alleviate emotional problems, or to learn
coping skills in dealing with everyday problems. These clients often expect coun-
selors to provide guidance or give advice and can be put off by this unstructured
approach.
A second shortcoming of the person-centered approach is that it is difficult to
translate the core therapeutic conditions into actual practice in certain cultures.
Communication of these core conditions must be consistent with the client’s cul-
tural framework. Consider, for example, the expression of therapist congruence and
empathy. Clients accustomed to indirect communication may not be comfortable
with direct expressions of empathy or self-disclosure on the therapist’s part.
A third shortcoming in applying the person-centered approach with clients
from diverse cultures pertains to the fact that this approach extols the value of an
internal locus of evaluation. The humanistic foundation of person-centered therapy
emphasizes dimensions such as self-awareness, freedom, autonomy, self-acceptance,
inner-directedness, and self-actualization. Cain (2010) points out that “persons
from collectivistic cultures are oriented less toward self-actualization and more
toward intimacy, connection, and harmony with others and toward what is best for
the community and the common good” (p. 143). The focus on development of indi-
vidual autonomy and personal growth may be viewed as being selfish in a culture
that stresses the common good.
Consider Lupe, a Latina client who values the interests of her family over her
self-interests. From a person-centered perspective she could be viewed as being in
danger of “losing her own identity” by being primarily concerned with her role in
taking care of others in the family. Rather than pushing her to make her personal
wants a priority, the counselor will explore Lupe’s cultural values and her level of
commitment to these values in working with her. It would be inappropriate for the
counselor to communicate a vision of the kind of woman she should be. (This topic
is discussed more extensively in Chapter 12.)
Despite these shortcomings, the person-centered approach offers many oppor-
tunities for working with clients from diverse cultures. There is great diversity
among any group of people, and there is room for a variety of therapeutic styles.
Counseling a culturally different client may require more activity and structuring
than is usually the case in a person-centered framework, but the potential positive
impact of a counselor who responds empathically to a culturally different client can-
not be overestimated.
S tan’s autobiography indicates that he has a sense of what he wants for his life. As a person-centered
therapist, I rely on his self-report of the way he views
himself rather than on a formal assessment and diag-
nosis. My concern is with understanding him from his
internal frame of reference. Stan has stated goals that
are meaningful for him. He is motivated to change
and seems to have sufficient anxiety to work toward
these desired changes. I have faith in Stan’s ability to
find his own way, and I trust that he has the necessary
resources for reaching his therapy goals. I encourage
Stan to speak freely about the discrepancy between
the person he sees himself as being and the person
he would like to become; about his feelings of being
Person-Centered Therapy Applied to the Case of Stan
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a failure, being inadequate; about his fears and uncer-
tainties; and about his hopelessness at times. I attempt
to create an atmosphere of freedom and security that
will encourage Stan to explore the threatening aspects
of his self-concept.
Stan has a low evaluation of his self-worth.
Although he finds it difficult to believe that others
really like him, he wants to feel loved. He says, “I hope
I can learn to love at least a few people, most of all,
women.” He wants to feel equal to others and not have
to apologize for his existence, yet most of the time he
feels inferior. By creating a supportive, trusting, and
encouraging atmosphere, I can help Stan learn to be
more accepting of himself, with both his strengths
and limitations. He has the opportunity to openly
express his fears of women, of not being able to work
with people, and of feeling inadequate and stupid. He
can explore how he feels judged by his parents and
by authorities. He has an opportunity to express his
guilt—that is, his feelings that he has not lived up to
his parents’ expectations and that he has let them and
himself down. He can also relate his feelings of hurt
over not having ever felt loved and wanted. He can
express the loneliness and isolation that he so often
feels, as well as the need to numb these feelings with
alcohol or drugs.
Stan is no longer totally alone, for he is taking
the risk of letting me into his private world of feel-
ings. Stan gradually gets a sharper focus on his
experiencing and is able to clarify his own feelings and
attitudes. He sees that he has the capacity to make his
own decisions. In short, our therapeutic relationship
frees him from his self-defeating ways. Because of the
caring and faith he experiences from me in our rela-
tionship, Stan is able to increase his own faith and
confidence in himself.
My empathy assists Stan in hearing himself and
accessing himself at a deeper level. Stan gradually
becomes more sensitive to his own internal messages
and less dependent on confirmation from others
around him. As a result of the therapeutic venture,
Stan discovers that there is someone in his life whom
he can depend on—himself.
Questions for Reflection
�� How would you respond to Stan’s deep feelings
of self-doubt? Could you enter his frame of refer-
ence and respond in an empathic manner that lets
Stan know you hear his pain and struggle without
needing to give advice or suggestions?
�� How would you describe Stan’s deeper struggles?
What sense do you have of his world?
�� To what extent do you think that the relation-
ship you would develop with Stan would help
him move forward in a positive direction? What,
if anything, might get in your way—either with
him or in yourself—in establishing a therapeutic
relationship?
Visit CengageBrain.com or watch the dVd for
the video program Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes,
Session 5 (person-centered therapy), for a demon-
stration of my approach to counseling Stan from
this perspective. This session focuses on exploring
the immediacy of our relationship and assisting
Stan in finding his own way.
P E R S o N – C E N T E R E d T H E R A P y 187
G wen arrives for this session moving quite slowly. She reports having been in pain for the past few
days. I asked her to describe the pain in her body, and
she explains that it is a full body achiness.
Gwen: I can’t sleep through the night, and I feel tired
all day long. I try to push through the achiness, but
sometimes I just want to sit down and not get up.
Therapist: Tell me more about this feeling.
Gwen: I don’t mean sit down and die, I mean sit
down and take a break from life for a while. I
have just been feeling down and stressed.
To gain a better understanding of how Gwen’s
pain has affected her week, I administer a brief rating
Person-Centered Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a person-centered perspective and applying this model to Gwen.
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scale at the beginning of this session. The Outcome
Rating Scale (ORS) is a short questionnaire developed
by Scott D. Miller that assesses how well a person has
been doing (individually, interpersonally, socially, and
overall well-being) during the last week. I explain that
the ORS will give us a quick look at her current level
of functioning and feeling. The ORS can also help
Gwen see which particular areas of her life hold the
most stress for her. Gwen marks the form quickly,
and the results indicate that personal well-being and
interpersonal relationships are her most significant
areas of challenge. This assessment provides a starting
point for discussing how our therapeutic relationship
is contributing to her overall well-being.
Therapist: Gwen, I hope that information is helpful
for you. Where would you like to start today?
Gwen: I need to work on the personal well-being
issues. I just want to unwind and relax a little
before I go back into my busy day. I get so tired
of running around so much. I seem to live in
an “overwhelm” mode. I am ready to retire that
way of living. I could use some balance in my life.
I know that’s why I have been feeling so achy.
It’s the stress I have been carrying. I can feel the
tension.
Therapist: Would you like to say more about the
sense of “overwhelm” you mentioned?
Gwen: I am always juggling between getting my
own house in order and putting out fires with
my mom’s health team or insurance. I work
hard at my job, and then I come home and need
to get my own house in order. I am stretched
in too many directions, and at the end of the
day I still feel like I am on call and can’t turn
my mind off. I lay down at night and feel all my
responsibilities whirling around in my mind.
Sometimes I just cover my head and hope
that everything will go away and I can at least
have some peace at night. I know nothing will
disappear from my list until I take it off and
that I have to make an effort to find space for
relaxation in my life.
Therapist: Hearing you explain what “overwhelm
mode” looks like for you gets my heart rate up
[immediacy]. Although you know that many
of your responsibilities will not diminish, you
would like to find some way of dealing with
them and find more peace in your life.
Gwen: Yes, but I don’t know where to begin. I can’t
seem to find time for relaxation.
Therapist: It sounds like you feel unsure about
where to start and whether you’ll find time for
yourself at all. I am wondering when you feel
somewhat relaxed.
Gwen: I feel best when I’m caught up with all my
projects at work and have some time for myself.
I like it when I have crossed some things off my
list of things to do. I used to reward myself with
a spa day when I finished a big project. I haven’t
done that in ages.
Therapist: As you talk about this time, I can see
how excited you are about crossing things off
your list and having time for yourself. That’s
when you really feel good about yourself—when
you’re accomplishing things yet you realize you
need to take care of yourself too.
Gwen: Before I became the caregiver for my mom, I
used to get to the gym about three days a week.
I loved doing dancing and yoga! It really made
a difference in my stress level. Working out just
fell by the wayside as my life got busier.
Therapist: That must be exhausting; you take care
of your mom, husband, grown kids, colleagues,
and everyone else. Yet I hear that you are not
taking care of yourself. How satisfied are you
about meeting your own needs right now?
Gwen: Not at all. I have totally abandoned myself. I
am feeling worn down.
Therapist: Tell me more about being worn down.
Gwen: I guess saying I am worn down is a bit extreme
[Gwen is smiling]. My body is definitely telling me
to slow down and focus on me for a change.
Therapist: So one side is telling you that you can’t
keep up this pace and you need to take care of
yourself, and the other side is saying, “Gwen,
you need to handle everything that’s being
thrown at you.”
Gwen: That sounds right. It’s been a while since I
actually paid attention to myself. I feel sad saying
that out loud. I know I want to do something
different. Even if it’s a small something!
188 C H A P T E R S E V E N
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P E R S o N – C E N T E R E d T H E R A P y 189
Therapist: You are disappointed in yourself for not
recognizing that you need a break, and yet you
seem determined to make some small change
now. Can you identify what you might begin to
do differently?
Gwen: I want to make myself a priority. I can
start taking my breaks at work again and use
that time to take care of me. I used to do some
stretching at my desk and walk around the
building. It was actually fun: we would do a
pedometer challenge at work. It was good. I
don’t know why I let all of that go. I just started
putting everyone and everything in front of me.
We even have a lunch time dance class I could go
to. I forgot how happy doing those little things
used to make me feel.
Therapist: It sounds like you regret that some of
those activities aren’t in you life. What would
it look like to make yourself a priority in some
small way?
Gwen: I guess I could find 15 minutes to do
something for myself. I could even go get my hair
done. Maybe a break in my regular routine would
be helpful. It’s been forever since I treated myself.
Therapist: With you changing your lifestyle, I want
to make sure you do it safely. I suggest you ask
your primary care physician about a physical
examination to determine any possible reasons
for the pain and physical symptoms you are
experiencing.
Gwen: That is a good idea, and I will follow up on
that suggestion.
Therapist: Before you leave, I want to give you
the Session Rating Scale (SRS). All you have to
do is rate today’s session based on four items:
our relationship, goals and topics, therapeutic
approach, and overall view of our time today.
It’s similar to the form you filled out at the
beginning of session.
Gwen takes a moment to fill out the form and
passes it back with marks reflecting that she felt heard
and that we talked about what she wanted to discuss.
She also marked that there was something missing
from the session, which gave us an opportunity to
identify what might be missing for her. Using the ORS
and the SRS is a good way to get Gwen’s feedback on
her own progress and her perception of the value of the
therapy session. As a therapist, I invite this feedback
and see it as a useful way of getting Gwen’s perspective.
In collaboration with Gwen, I strive to make adjust-
ments in my work with her based on her feedback.
Gwen then says a few words about how she is feeling.
Gwen: I am definitely not as tense as I was when I
first came in. I needed to get some things off of
my chest. I would have liked more suggestions
from you on what I need to do next. I know you
don’t have the magic answer, but sometimes that’s
just what I want.
Therapist: Thanks for your honest feedback. The
goal is for you to be the director of this session
and of your life. As you lead the way, your own
answers will surface to assist you in resolving
some of your challenges. In today’s session you
clearly identified areas of stress, and then you
reconnected with activities that brought you
peace and relaxation in the past. You were able
to find your answers within yourself.
Person-centered therapy is a collaborative journey
driven by what the client brings into the session. I fol-
lowed the lead provided by Gwen of what was troubling
her and attempted to work within the framework of
what she said she wanted. At each step along the way,
I show empathy and compassion for her challenges as
she works to rebuild self-trust and reconnect to her
own sense of personal power and value.
Questions for Reflection
�� What are your thoughts about soliciting client
feedback using rating scales such as the ORS and
the SRS?
�� Gwen wants more suggestions from her therapist.
If you were her therapist, how would you intervene
with her when she wants more direction from you?
�� How does person-centered therapy fit with who
you are as a person? Would you be comfortable
in mostly identifying the client’s underlying mes-
sages as the therapist did in this session?
�� Frequently person-centered therapists identify con-
flicts or the competing sides of an issue. Where did
the therapist do this in her dialogue with Gwen?
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190 C H A P T E R S E V E N
Summary and Evaluation
Summary
Person-centered therapy is based on a philosophy of human nature that postulates
an innate striving for self-actualization. Carl Rogers’s view of human nature is phe-
nomenological; that is, we structure ourselves according to our perceptions of real-
ity. We are motivated to actualize ourselves in the reality that we perceive.
Rogers’s theory rests on the assumption that clients can understand the factors
in their lives that are causing them to be distressed. They also have the capacity for
self-direction and constructive personal change. Change will occur if a congruent
therapist makes psychological contact with a client in a state of anxiety or incongru-
ence. It is essential for the therapist to establish a relationship the client perceives
as genuine, accepting, and understanding. Therapeutic counseling is based on an
I/Thou, or person-to-person, relationship in the safety and acceptance of which cli-
ents drop their defenses and come to accept and integrate aspects that they have
denied or distorted. The person-centered approach emphasizes this personal rela-
tionship between client and therapist; the therapist’s attitudes are more critical than
are knowledge, theory, or techniques employed. In the context of this relationship,
clients unleash their growth potential and become more of the person they are capa-
ble of becoming. An abundance of research supports the notion that the human
elements of psychotherapy (client factors, therapist effects, and the therapeutic alli-
ance) are far more important than models and techniques in the effectiveness and
outcomes of therapy (Elkins, 2016).
This approach places primary responsibility for the direction of therapy on
the client. In the therapeutic context, individuals have the opportunity to decide
for themselves and come to terms with their own personal power. The underlying
assumption is that no one knows the client better than the client; in short, the cli-
ent is viewed as an expert on his or her own life (Cain, 2010). The general goals of
therapy are becoming more open to experience, achieving self-trust, developing an
internal source of evaluation, and being willing to continue growing. Specific goals
are not suggested for clients; rather, clients choose their own values and goals. Cur-
rent applications of the theory emphasize more active participation by the therapist
than was the case earlier. Counselors are now encouraged to be fully involved as
persons in the therapeutic relationship. More latitude is allowed for therapists to
express their reactions and feelings as they are appropriate to what is occurring in
therapy. Person-centered practitioners are willing to be transparent about persistent
feelings that exist in their relationships with clients (Watson et al., 2011). It is the
therapist’s job to adapt and accommodate in a manner that works best for each
client, which means being flexible in the application of methods in the counseling
process (Cain, 2010).
Contributions of the Person-Centered Approach
When Carl Rogers founded nondirective counseling more than 70 years
ago, there were very few other therapeutic models. The longevity of this approach is
certainly a factor to consider in assessing its influence. Rogers had, and his theory
continues to have, a major impact on the field of counseling and psychotherapy.
LO11
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P E R S o N – C E N T E R E d T H E R A P y 191
When he introduced his revolutionary ideas in the 1940s, he provided a powerful
and radical alternative to psychoanalysis and to the directive approaches then prac-
ticed. Rogers was a pioneer in shifting the therapeutic focus from an emphasis on
technique and reliance on therapist authority to that of the power of the therapeu-
tic relationship.
Kirschenbaum (2009) contends that the scope and influence of Rogers’s work
has continued well beyond his death; the person-centered approach is alive, well, and
expanding. Today there is not one version of person-centered therapy, but a number
of continuously evolving person-centered psychotherapies (Cain, 2010). Although
few psychotherapists claim to have an exclusive person-centered theoretical orienta-
tion, the philosophy and principles of this approach permeate the practice of most
therapists. Other schools of therapy are increasingly recognizing the centrality of
the therapeutic relationship as a route to therapeutic change.
Person-centered therapy is strongly represented in Europe, and there is continu-
ing interest in this approach in both South America and the Far East. The person-
centered approach has established a firm foothold in British universities, and some
of the most in-depth training of person-centered counselors is taking place in the
United Kingdom today (N. Rogers, 2011).
As we have seen, Natalie Rogers has made a significant contribution to the
application of the person-centered approach by incorporating the expressive arts
as a medium to facilitate healing and social change, primarily in a group setting.
She has been instrumental in the evolution of the person-centered approach using
nonverbal methods to enable individuals to heal and to develop. Many individuals
who have difficulty expressing themselves verbally can find new possibilities for self-
expression through nonverbal channels and through the expressive arts (N. Rogers,
2011). Cain (2010) believes “Natalie Rogers’s expressive arts therapy represents a
major innovation in practice and helped open the way for other person-centered
therapists to expand the variety and range of practice” (p. 60).
Emphasis on Research One of Carl Rogers’s contributions to the field of
psychotherapy was his willingness to state his concepts as testable hypotheses and
to submit them to research. He literally opened the field to research. He was truly a
pioneer in his insistence on subjecting the transcripts of therapy sessions to critical
examination and applying research technology to counselor–client dialogues.
According to Cain (2010), an enormous body of research, conducted over a period of
70 years, supports the effectiveness of the person-centered approach. This research
is ongoing in many parts of the world and continues to expand and refine our
understanding of what constitutes effective psychotherapy. Cain (2010) concludes,
“person centered therapy is as vital and effective as it has ever been and continues to
develop in ways that will make it increasingly so in the years to come” (p. 169).
Even his critics give Rogers credit for having conducted and inspired others to
conduct extensive studies of counseling process and outcome. Rogers presented a
challenge to psychology to design new models of scientific investigation capable of
dealing with the inner, subjective experiences of the person. His theories of therapy
and personality change have had a tremendous heuristic effect, and though much
controversy surrounds this approach, his work has challenged practitioners and
theoreticians to examine their own therapeutic styles and beliefs.
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192 C H A P T E R S E V E N
Limitations and Criticisms of the Person-Centered Approach
Although I applaud person-centered therapists for their willingness to subject their
hypotheses and procedures to empirical scrutiny, some researchers have been criti-
cal of the methodological errors contained in some of these studies. Accusations of
scientific shortcomings involve using control subjects who are not candidates for
therapy, failing to use an untreated control group, failing to account for placebo
effects, reliance on self-reports as a major way to assess the outcomes of therapy, and
using inappropriate statistical procedures. In all fairness, these accusations apply to
the research on many other therapeutic approaches as well.
There is a similar limitation shared by both the person-centered and existential
(experiential) approaches. Neither of these therapeutic modalities emphasizes the
role of techniques aimed at bringing about change in clients’ behavior. Proponents
of psychotherapy manuals, or manualized treatment methods for specific disorders,
find serious limitations in the experiential approaches due to their lack of attention
to proven techniques and strategies. Those who call for accountability as defined by
evidence-based practices within the field of mental health also are quite critical of
the experiential approaches.
I do not believe manualized treatment methods can be considered the gold stan-
dard in psychotherapy, however. There is good research demonstrating that tech-
niques account for only 15% of client outcome (see Duncan et al., 2010), whereas
contextual factors have powerful effects on what happens in therapy (Elkins, 2009,
2012, 2016). Research points to relational and client factors as the main predictors of
effective therapy. Furthermore, the evaluation of evidence-based practices has been
broadened to include best available research; the expertise of the clinician; and cli-
ent characteristics, culture, and preferences (see Norcross, Hogan, & Koocher, 2008).
A potential limitation of the person-centered approach is that some students-
in-training and practitioners with this orientation may have a tendency to be very
supportive of clients without being challenging. Out of their misunderstanding of
the basic concepts of the approach, some have limited the range of their responses
and counseling styles mainly to reflections and empathic listening. Although there
is value in accurately and deeply hearing a client and in reflecting and communicat-
ing understanding, counseling entails more than this. I believe that the therapeutic
core conditions are necessary for therapy to succeed, yet I do not see them as being
sufficient conditions for change for all clients at all times. From my perspective, these
basic attitudes are the foundation on which counselors must then build the skills of
therapeutic intervention. Motivational interviewing rests on the therapeutic core
conditions, for example, but MI employs a range of strategies that enables clients to
develop action plans leading to change.
A related challenge for counselors using this approach is to truly support clients in
finding their own way. Counselors sometimes experience difficulty in allowing clients to
decide their own specific goals in therapy. It is easy to give lip service to the concept of cli-
ents’ finding their own way, but it takes considerable respect for clients and faith on the
therapist’s part to encourage clients to listen to themselves and follow their own direc-
tions, particularly when they make choices that are not what the therapist hoped for.
More than any other quality, the therapist’s genuineness determines the power
of the therapeutic relationship. If therapists submerge their unique identity and style
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P E R S o N – C E N T E R E d T H E R A P y 193
in a passive and nondirective manner, they are not likely to affect clients in powerful
ways. Therapist authenticity and congruence are so vital to this approach that those
who practice within this framework must feel natural in doing so and must find a
way to express their own reactions to clients. If not, a real possibility is that person-
centered therapy will be reduced to a bland, safe, and ineffectual approach.
Self-Reflection and Discussion Questions
1. To what degree do you believe clients have the ability to understand
and resolve their own problems without a great deal of advice or sug-
gestions from a therapist?
2. This therapy approach places considerable importance on congruence
(realness or genuineness) on the part of the therapist. How confident
are you that you will be able to be genuine in your interaction with your
clients?
3. The therapeutic relationship is given prominence in this theory. What
kind of relationship do you hope to create with your clients? Identify
the characteristics you deem most important.
4. Empathy is a core ingredient in person-centered therapy. What do you
think you can do to increase your ability to develop empathy toward a
client who you perceive of as being difficult?
5. How would it be for you to practice by relying on a minimum of tech-
niques and instead staying tuned into a client’s moment-by-moment
experience?
Where to Go From Here
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, you will see a con-
crete illustration of how I view the therapeutic relationship as the foundation for our
work together. Refer especially to Session 1 (“Beginning of Counseling”), Session 2
(“The Therapeutic Relationship”), and Session 3 (“Establishing Therapeutic Goals”)
for a demonstration of how I apply principles from the person-centered approach to
my work with Ruth.
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) by going to www.counseling
.org; click on the Resource button and then select the Podcast Series. For Chapter 7,
Carl Rogers and the Person-Centered Approach, look for Podcast 7 by Dr. Howard
Kirschenbaum.
Other Resources
The American Psychological Association offers the following DVDs in their Psycho-
therapy Video Series:
Greenberg, L. S. (2010). Emotion-Focused Therapy Over Time
Cain, D. J. (2010). Person-Centered Therapy Over Time
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194 C H A P T E R S E V E N
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews featuring Natalie Rogers, Rollo May, and more.
New articles, interviews, blogs, therapy cartoons, and videos are published monthly.
DVDs relevant to this chapter are available at www.psychotherapy.net and include
the following:
Rogers, N. (1997). Person-Centered Expressive Arts Therapy
May, R. (2007). Rollo May on Existential Psychotherapy
The Association for the Development of the Person-Centered Approach (ADPCA)
is an interdisciplinary and international organization that consists of a network of
individuals who support the development and application of the person-centered
approach. Membership includes a subscription to the Person-Centered Journal, the
association’s newsletter, a membership directory, and information about the annual
meeting. ADPCA also provides information about continuing education and super-
vision and training in the person-centered approach. For information about the
Person-Centered Journal, contact the editor (Jon Rose).
Association for the Development of the Person-Centered Approach, Inc.
www.adpca.org
The Association for Humanistic Psychology (AHP) is devoted to promoting per-
sonal integrity, creative learning, and active responsibility in embracing the chal-
lenges of being human in these times. Information about the Journal of Humanistic
Psychology is available from the Association for Humanistic Psychology or at the pub-
lisher’s website.
Association for Humanistic Psychology
www.ahpweb.org
Division 32 of APA, Society for Humanistic Psychology, represents a constella-
tion of “humanistic psychologies” that includes the earlier Rogerian, transpersonal,
and existential orientations as well as recently developing perspectives. Division 32
seeks to contribute to psychotherapy, education, theory, research, epistemological
diversity, cultural diversity, organization, management, social responsibility, and
change. The division has been at the forefront in the development of qualitative
research methodologies. The Society for Humanistic Psychology offers journal
access to The Humanistic Psychologist. Information about membership, conferences,
and journals is available from the website of Division 32.
Society for Humanistic Psychology
www.societyforhumanisticpsychology.com/
The Carl Rogers CD-ROM is a visually beautiful and lasting archive of the life
and works of the founder of humanistic psychology. It includes excerpts from his 16
books, over 120 photographs spanning his lifetime, and award-winning video foot-
age of two encounter groups and Carl’s early counseling sessions. It is an essential
resource for students, teachers, libraries, and universities. It is a profound tribute to
one of the most important thinkers, influential psychologists, and peace activists of
the 20th century. Developed for Natalie Rogers, PhD, by Mindgarden Media, Inc.
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P E R S o N – C E N T E R E d T H E R A P y 195
Carl Rogers: A Daughter’s Tribute
www.nrogers.com
The Center for Studies of the Person (CSP) offers workshops, training seminars,
experiential small groups, residential workshops, and sharing of learning in com-
munity meetings.
Center for Studies of the Person
www.centerfortheperson.org
For training in expressive art therapy, join Natalie Rogers, Sue Ann Herron, and
Terri Goslin-Jones in their course, “Expressive Arts for Healing and Social Change:
A Person-Centered Approach” at Sofia University. This 16-unit certificate program
requires six weeks of study spread over two years at a retreat center north of San Fran-
cisco. The expressive arts within a person-centered counseling framework program
includes counseling demonstrations, practice counseling sessions, readings, discus-
sions, papers, and a creative project to teach experiential and theoretical methods.
Training in the Person-Centered Approach to Expressive Arts
www.nrogers.com
Sofia University
www.sofia.edu/
Recommended Supplementary Readings
On Becoming a Person (C. Rogers, 1961) is one of the
best primary sources for further reading on person-
centered therapy. This classic book is a collection of
Rogers’s articles on the process of psychotherapy, its
outcomes, the therapeutic relationship, education,
family life, communication, and the nature of the
healthy person.
A Way of Being (C. Rogers, 1980) contains a series of
writings on Rogers’s personal experiences and per-
spectives, as well as chapters on the foundations and
applications of the person-centered approach.
The Creative Connection: Expressive Arts as Healing
(N. Rogers, 1993) is a practical, spirited book lav-
ishly illustrated with color and action photos and
filled with fresh ideas to stimulate creativity, self-
expression, healing, and transformation. Natalie
Rogers combines the philosophy of her father with
the expressive arts to enhance communication
between client and therapist.
The Life and Work of Carl Rogers (Kirschenbaum,
2009) is a definitive biography of Carl Rogers that
follows his life from his early childhood through his
death. This book illustrates the legacy of Carl Rog-
ers and shows his enormous influence on the field of
counseling and psychotherapy.
Person-Centered Psychotherapies (Cain, 2010) con-
tains a clear discussion of person-centered theory,
the therapeutic process, evaluation of the approach,
and future developments.
Humanistic Psychology: A Clinical Manifesto (Elkins,
2009) offers an insightful critique of the medical
model of psychotherapy and the myth of empirically
supported treatments. The author calls for a rela-
tionship-based approach to psychotherapy that can
provide both individual and social transformation.
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197
8Gestalt Therapy
1. Understand the evolution
of this approach from the
pioneering work of Fritz Perls
to contemporary relational
approaches.
2. Define the philosophy and basic
assumptions underlying Gestalt
theory and therapy.
3. Identify these key concepts of
the approach: here and now,
awareness, dealing with unfinished
business, contact and resistance
to contact, body language, and
the role of experiments in therapy.
4. Describe how the I/Thou
relationship is central to the use
of experiments in the therapy
process.
5. Understand the role of
confrontation in contemporary
relational Gestalt therapy.
6. Explain these standard Gestalt
therapy interventions: role playing,
future projection, making the
rounds, staying with the feeling,
working with dreams, and creating
experiments based on here-and-
now awareness.
7. Understand the application of
Gestalt therapy to group counseling.
8. Describe the practice of Gestalt
therapy from a multicultural
perspective.
9. Evaluate the contributions,
strengths, and limitations of the
Gestalt approach.
L e a r n i n g O b j e c t i v e s
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198 C H A P T E R E I G H T
MIRIAM POLSTER (1924–2001) earned
her undergraduate degree in music. She
was trained as a classical vocalist and a
performer of operatic music. Her artistic
gifts remained with her throughout her
personal and professional life. M. Polster
led workshops in which music served as a
framework for assisting clients in explor-
ing personal experiences.
She was a strong advocate of the
relational dimension of Gestalt therapy,
a counterpoint to the skewed stereotype
of it as confrontational and technically
narrow. The freshness of her perspectives, the clarity
of her language, and the excitement evoked by her
radiance all served to raise the charismatic poten-
tial of the therapist who entered into the realm of
simple fascination with the way people
lived their lives. The long arc of her influ-
ence was drawn by a feminine candor and
conversational mutuality that achieved
its strength through presence and intelli-
gence more than through forcefulness; of
relationship more than through manipu-
lation; of optimism more than metallic
rationalism; and, at last, of a wisdom-
based tension that created a natural pro-
gression of experience.
Gestalt Therapy Integrated: Contours of
Theory and Practice (1973), coauthored
with her husband, Erving Polster, is considered a clas-
sic and a benchmark in the evolution of Gestalt ther-
apy. In Eve’s Daughters: The Forbidden Heroism of Women
(1992), M. Polster painted an eye-opening picture of
Miriam Polster
M
iri
am
P
ol
st
er
ERVING POLSTER (b. 1922) is still pro-
fessionally active and gives presentations,
therapy demonstrations, and workshops.
He is regularly featured at the Evolution
of Psychotherapy conference and the
Brief Therapy conference. Erving Polster
writes the following about his connection
with Gestalt Therapy:*
I first became aware of Gestalt Therapy
in 1953 when I attended a workshop
in Cleveland with Frederick Perls. He
was masterful in the therapy sessions
he conducted with those of us who attended the
workshop. Two aspects of the experience stand
out for me. One was the combination of simplic-
ity and power in both his concepts and his thera-
peutic work. The second was the surprising public
nature of the personal explorations. This openness
was revelatory in a process that had been steeped
in privacy. Yet this freedom seemed both natural
and daring, an enchanting exemplification of the
drama of living.
These explorations led to the formation of the
Gestalt Institute of Cleveland, where I was faculty
chairman from 1956 to 1973. The courses I created
there composed a point of view that became the
foundation of Gestalt Therapy Integrated: Contours of
Theory and Practice (1973), a book coauthored with
my wife, Miriam. We moved to San Diego in
1973 and opened the Gestalt Training Cen-
ter. People came there for 25 years from all
over the world for extensive training work
with us. Those were exciting and productive
days, and Miriam and I had the pleasure of
our partnership in developing our ideas and
our training programs.
Some years later, I wrote Every Person’s
Life Is Worth a Novel (1987b) and A Popula-
tion of Selves: A Therapeutic Exploration of
Personality Diversity (1995) and coauthored
an anthology of Miriam’s and my writings
titled From the Radical Center: The Heart of Gestalt
Therapy (1999). Miriam died in 2001, at which
point we had both been retired for two years. After
she died, I came out of retirement and began to
explore a new theme, advocating the advancement
of psychotherapy principles from a private office
procedure into a communal application. I have
written one book about this, Uncommon Ground
(2006), and am currently completing another
book, A Life Focus Revolution: The Mind’s Answer to
the Speed of Living.
Erving Polster
Er
vi
ng
P
ol
st
er
*I invited Erving Polster to write his biography in the first person
and his wife Miriam’s biography, which he kindly accepted. My
gratitude to Erv for providing these sketches of the Polsters’
contributions to the development of Gestalt therapy.
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G E s TA lT T H E R A P y 199
Introduction
Gestalt therapy is an existential, phenomenological, and process-based
approach created on the premise that individuals must be understood in the context
of their ongoing relationship with the environment. Awareness, choice, and responsi-
bility are cornerstones of practice. The initial goal is for clients to expand their aware-
ness of what they are experiencing in the present moment. Through this awareness,
change automatically occurs. The approach is phenomenological because it focuses on
the client’s perceptions of reality and existential because it is grounded in the notion
that people are always in the process of becoming, remaking, and rediscovering them-
selves. As an existential approach, Gestalt therapy gives special attention to existence
as individuals experience it and affirms the human capacity for growth and healing
through interpersonal contact and insight (Yontef, 1995). In a nutshell, this approach
focuses on the here and now, the what and how of experiencing, the authenticity of the
therapist, active dialogic inquiry and exploration, and the I/Thou of relating (Brown,
2007; Resnick, 2015; Wheeler & Axelsson, 2015; Yontef & Jacobs, 2014).
Fritz Perls was the main originator and developer of Gestalt therapy. Although
Perls was influenced by psychoanalytic concepts, he took issue with Freud’s theory
on a number of grounds. Whereas Freud’s view of human beings is basically mecha-
nistic, Perls stressed a holistic approach to personality. Freud focused on repressed
intrapsychic conflicts from early childhood, whereas Perls valued examining the
present situation. The Gestalt approach focuses much more on process than on con-
tent. This process involves Gestalt therapists putting themselves as fully as possible
into the experience of the client without judgment, analyzing, or interpreting, while
concurrently holding a sense of one’s individual, independent presence. Therapists
devise experiments designed to increase clients’ awareness of what they are doing
and how they are doing it moment to moment. Perls asserted that how individuals
behave in the present moment is far more crucial to self-understanding than why
they behave as they do. Awareness usually involves insight and sometimes introspec-
tion, but Gestalt therapists consider it to be much more than either. A defining char-
acteristic of awareness is paying attention to the flow of your experience and being in
contact with what you are doing when you are doing it (Resnick, 2015).
Self-acceptance, knowledge of the environment, responsibility for choices, and
the ability to make contact with their field (a dynamic system of interrelationships)
and the people in it are important awareness processes and goals, all of which are
LO1
the contributions and the character of women in our
society. She spelled out the historical role of women
and their special heroic contributions to social prog-
ress. However, she went further than their overlooked
heroism by also postulating a picture of heroism
itself. She brightened the concept by reminding us
of the heroism that is a part of everyday living. This
interweaving of women’s heroism with the heroism of
everyday life accented the value of women’s potential
for effecting new social norms. Women’s heroism
had been taken for granted and was relegated to the
background of social importance. M. Polster tied this
social expansion of feminine heroism, often part of
their ministrations in the world of everyday living, to
an enlivened understanding of the subtle role of ordi-
nary heroism of people at large.
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200 C H A P T E R E I G H T
based on a here-and-now experiencing that is always changing. Clients are expected
to do their own seeing, feeling, sensing, and interpreting, as opposed to waiting pas-
sively for the therapist to provide them with insights and answers.
contemporary relational gestalt therapy stresses dialogue and the I/Thou
relationship between client and therapist. Therapists emphasize the therapeutic
relationship and work collaboratively with clients in a search for understanding
(Wheeler & Axelsson, 2015; Yontef & Schulz, 2013). Following the lead of Laura
Perls and the “Cleveland school” when Erving and Miriam Polster and Joseph Zinker
were on the faculty in the 1960s and 1970s, this model includes more support and
increased sensitivity and compassion in therapy than the confrontational and
dramatic style of Fritz Perls (Yontef, 1999). The majority of today’s Gestalt ther-
apists emphasizes support, acceptance, empathy, respect, and dialogue as well as
confrontation.
Gestalt therapy is lively and promotes direct experiencing rather than the
abstractness of talking about situations. Gestalt therapy is an experiential approach
in that clients come to grips with what and how they are thinking, feeling, and doing
as they interact with the therapist. Gestalt practitioners value being fully present
during the therapeutic encounter with the belief that growth occurs out of genuine
contact between client and therapist.
Visit CengageBrain.com or watch the DVD for the video program on Chapter 8, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Key Concepts
View of Human Nature
The Gestalt view of human nature is rooted in existential philosophy, phe-
nomenology, and field theory. Genuine knowledge is the product of what is imme-
diately evident in the experience of the perceiver. Therapy aims at awareness and
contact with the environment, which consists of both the external and internal
worlds. The quality of contact with aspects of the external world (for example, other
people) and the internal world (for example, parts of the self that are disowned) are
monitored. The process of “reowning” parts of oneself that have been disowned and
the unification process proceed step by step until clients can carry on with their own
personal growth. By becoming aware, clients become able to make informed choices
and thus to live a more meaningful existence.
Due to this view of human nature, Fritz Perls (1969a) practiced Gestalt therapy
paternalistically. Clients have to grow up, stand on their own two feet, and “deal
with their life problems themselves” (p. 225). Perls’s style of doing therapy involved
two personal agendas: moving the client from environmental support to self-support
and reintegrating the disowned parts of one’s personality. His conception of human
nature and these two agendas set the stage for a variety of techniques and for his
confrontational style of conducting therapy. He was a master at intentionally frus-
trating clients to enhance their awareness.
A basic assumption of Gestalt therapy is that individuals have the capacity
to self-regulate when they are aware of what is happening in and around them.
LO2
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G E s TA lT T H E R A P y 201
Therapy provides the setting and opportunity for that awareness to be supported
and restored. The therapist is attentive to the client’s present experience and trusts
in the process, thereby assisting the client in moving toward increased awareness,
contact, and integration (Brown, 2007).
The Gestalt theory of change posits that the more we work at becoming who or
what we are not, the more we remain the same. Fritz’s good friend and psychiatrist
colleague Arnie Beisser (1970) suggested that authentic change occurs more from
being who we are than from trying to be who we are not. Beisser called this simple
tenet the paradoxical theory of change. We are constantly moving between who
we “should be” and who we “are.” Gestalt therapists ask clients to invest themselves
fully in their current condition rather than striving to become who they should be.
Gestalt therapists believe people change and grow when they experience who they
really are in the world (Yontef & Schulz, 2013).
Some Principles of Gestalt Therapy Theory
Several basic principles underlying the theory of Gestalt therapy are briefly
described in this section: holism, field theory, the figure-formation process, and
organismic self-regulation. Other key concepts of Gestalt therapy are developed in
more detail in the sections that follow.
Holism Gestalt is a German word meaning a whole or completion, or a form that
cannot be separated into parts without losing its essence. All of nature is seen as a
unified and coherent whole, and the whole is different from the sum of its parts.
Because Gestalt therapists are interested in the whole person, they place no superior
value on a particular aspect of the individual. Gestalt practice attends to a client’s
thoughts, feelings, behaviors, body, memories, and dreams.
Field Theory Gestalt therapy is based on field theory, which, simply put, asserts
that the organism must be seen in its environment, or in its context, as part of the
constantly changing field. Gestalt therapists pay attention to and explore what is
occurring at the boundary between the person and the environment. Emphasis may
be on a figure (those aspects of the individual’s experience that are most salient at
any moment) or the ground (those aspects of the client’s presentation that are often
out of his or her awareness). Cues to this background can be found on the surface
through physical gestures, tone of voice, demeanor, and other nonverbal content.
This is often referred to by Gestalt therapists as “attending to the obvious,” while
paying attention to how the parts fit together, how the individual makes contact
with the environment, and integration.
The Figure-Formation Process Derived from the study of visual perception by a
group of Gestalt psychologists, the figure-formation process tracks how the individual
organizes experience from moment to moment as some aspect of the environmental
field emerges from the background and becomes the focal point of the individual’s
attention and interest. For example, imagine seeing a woman on a hill in the distance.
You do not see her clearly but receive an overall impression of this figure: a Gestalt. As
you move closer, you gain more awareness of this figure and she becomes increasingly
LO3
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202 C H A P T E R E I G H T
clear and more detailed: you see her face and the way she buttons her blouse. In
the figure-formation process, contemporary Gestalt therapists facilitate the client’s
movement toward and away from this figure of interest. The dominant needs of the
individual at a given moment influence this process (Frew, 1997).
Organismic Self-Regulation The figure-formation process is intertwined with
the principle of organismic self-regulation, a process by which equilibrium is
“disturbed” by the emergence of a need, a sensation, or an interest. Organisms will
do their best to regulate themselves, given their own capabilities and the resources
of their environment (Latner, 1986). Individuals can take actions and make contacts
to restore equilibrium or to contribute to growth and change. What emerges in
therapeutic work is what is of interest to the client or what the client needs to
gain equilibrium or to change. Gestalt therapists direct the client’s awareness to
the figures that emerge from the background during a therapy session and use the
figure-formation process as a guide for the focus of therapeutic work.
Contact and Resistances to Contact
In Gestalt therapy contact is necessary if change and growth are to occur. contact
is made by seeing, hearing, smelling, touching, and moving. Effective contact means
interacting with nature and with other people without losing one’s sense of individ-
uality. Prerequisites for good contact are clear awareness, full energy, and the ability
to express oneself. Contact between therapist and client are key to Gestalt therapy
practice (Yontef & Schulz, 2013; Zinker, 1978). Miriam Polster (1987) claimed that
contact is the lifeblood of growth. It is the continually renewed creative adjustment
of individuals to their environment. It entails zest, imagination, and creativity.
There are only moments of this type of contact, so it is most accurate to think of
levels of contact rather than a final state to achieve. After a contact experience, there
is typically a withdrawal to integrate what has been learned. Gestalt therapists talk
about the two functions of boundaries: to connect and to separate. Both contact
and withdrawal are necessary and important to healthy functioning.
Gestalt therapists also focus on interruptions, disturbances, and resistances to
contact, which were developed as coping processes but often end up preventing us
from experiencing the present in a full and real way. Resistances are typically adopted
out of our awareness and, when they function in a chronic way, can contribute to
dysfunctional behavior. Because resistances are developed as a means of coping with
life situations, they possess positive qualities as well as problematic ones, and many
contemporary Gestalt therapists refer to them as “contact boundary phenomena.”
Polster and Polster (1973) describe five different kinds of contact boundary distur-
bances: introjection, projection, retroflection, deflection, and confluence.
introjection is the tendency to uncritically accept others’ beliefs and standards
without assimilating them to make them congruent with who we are. These introj-
ects remain alien to us because we have not analyzed and restructured them. When
we introject, we passively incorporate what the environment provides rather than
clearly identifying what we want or need. If we remain in this stage, our energy is
bound up in taking things as we find them and believing that authorities know what
is best for us rather than working for things ourselves.
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G E s TA lT T H E R A P y 203
Projection is the reverse of introjection. In projection we disown certain aspects
of ourselves by assigning them to the environment. Those attributes of our person-
ality that are inconsistent with our self-image are disowned and put onto, assigned
to, and seen in other people; thus, blaming others for lots of our problems. By seeing
in others the very qualities that we refuse to acknowledge in ourselves, we avoid tak-
ing responsibility for our own feelings and the person who we are, and this keeps us
powerless to initiate change. People who use projection as a pattern tend to feel that
they are victims of circumstances, and they believe that people have hidden mean-
ings behind what they say.
retroflection consists of turning back onto ourselves what we would like to
do to someone else or doing to ourselves what we would like someone else to do
to or for us. This process is principally an interruption of the action phase in the
cycle of experience and typically involves a fair amount of anxiety. People who rely
on retroflection tend to inhibit themselves from taking action out of fear of embar-
rassment, guilt, and resentment. People who self-mutilate or who injure themselves,
for example, are often directing aggression inward out of fear of directing it toward
others. Depression and psychosomatic complaints are often created by retroflecting.
Typically, these maladaptive styles of functioning are adopted outside of our aware-
ness; part of the process of Gestalt therapy is to help us discover a self-regulatory
system so that we can deal realistically with the world.
Deflection is the process of distraction or veering off, so that it is difficult
to maintain a sustained sense of contact. We attempt to diffuse or defuse con-
tact through the overuse of humor, abstract generalizations, and questions rather
than statements (Frew, 1986). When we deflect, we speak through and for oth-
ers, beating around the bush rather than being direct and engaging the environ-
ment in an inconsistent and inconsequential basis, which results in emotional
depletion.
confluence involves blurring the differentiation between the self and the envi-
ronment. As we strive to blend in and get along with everyone, there is no clear
demarcation between internal experience and outer reality. Confluence in relation-
ships involves the absence of conflicts, slowness to anger, and a belief that all parties
experience the same feelings and thoughts we do. This style of contact is character-
istic of clients who have a high need to be accepted and liked, thus finding enmesh-
ment comfortable. This condition makes genuine contact extremely difficult. A
therapist might assist clients who use this channel of resistance by asking questions
such as: “What are you doing now?” “What are you experiencing at this moment?”
“What do you want right now?”
Terms such as interruptions in contact or boundary disturbance refer to the charac-
teristic styles people employ in their attempts to control their environment through
one of these channels of resistance. The premise in Gestalt therapy is that contact is
both normal and healthy, and clients are encouraged to become increasingly aware
of their dominant style of blocking contact and their use of resistance. Today’s
Gestalt therapists readily attend to how clients interrupt contact, approaching the
interruptive styles with respect and taking each style seriously, knowing that it has
served an important function in the past. It is important to explore what the resis-
tance does for clients: what it protects them from, and what it keeps them from
experiencing.
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204 C H A P T E R E I G H T
The Now
One of the main contributions of the Gestalt approach is its emphasis on learn-
ing to appreciate and fully experience the present moment. Focusing on the past
and the future can be a way to avoid coming to terms with the present. Polster and
Polster (1973) developed the thesis that “power is in the present.” It is a common
tendency for clients to invest their energies in bemoaning their past mistakes and
ruminating about how life could and should have been different or engaging in
endless resolutions and plans for the future. As clients direct their energy toward
what was or what might have been or live in fantasy about the future, the power of
the present diminishes.
Phenomenological inquiry involves paying attention to what is occurring
now. Most people can stay in the present for only a short time and are inclined to
find ways of interrupting the flow of the present. Instead of experiencing their feel-
ings in the here and now, clients often talk about their feelings, almost as if their
feelings were detached from their present experiencing. One of the aims of Gestalt
therapy is to help clients to become increasingly aware of their present experience.
To help the client make contact with the present moment, Gestalt therapists
ask “what” and “how” questions, but rarely ask “why” questions. To promote “now”
awareness, the therapist encourages a dialogue in the present tense by asking ques-
tions like these: “What is happening now?” “What is going on now?” “What are you
experiencing as you sit there and attempt to talk?” “What is your awareness at this
moment?” “How are you experiencing your fear?” “How are you attempting to with-
draw at this moment?” “How is it for you to be with me in this room now?” Phenom-
enological inquiry also involves suspending any preconceived ideas, assumptions, or
interpretations concerning the meaning of a client’s experience.
For example, if Josephine begins to talk about sadness, pain, or confusion, the
Gestalt therapist invites her to experience her sadness, pain, or confusion now. As
she attends to the present experience, the therapist gauges how much anxiety or
discomfort is present and chooses further interventions accordingly. The therapist
might choose not to comment as Josephine moves away from the present moment,
only to extend another invitation several minutes later. If a feeling emerges, the ther-
apist might suggest an experiment that would help Josephine to increase her aware-
ness of the feeling, such as exploring where and how she experiences it. Likewise, if
a thought or idea emerges, introducing an experiment can help her delve into the
thought, explore it more fully, and consider its effects and possible ramifications.
Gestalt therapists recognize that the past will make regular appearances in the
present moment, usually because of some lack of completion of that past experi-
ence. When the past seems to have a significant bearing on clients’ present attitudes
or behavior, it is dealt with by bringing it into the present as much as possible.
When clients speak about their past, the therapist may ask them to reenact it as
though they were living it now. The therapist directs clients to “bring the fantasy
here” or “tell me the dream as though you were having it now,” striving to help
them relive what they experienced earlier. For example, rather than talking about
a past childhood trauma with her father, a client becomes the hurt child and talks
directly to her father in fantasy, or by imagining him being present in the room in
an empty chair.
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G E s TA lT T H E R A P y 205
Unfinished Business
When figures emerge from the background but are not completed and resolved, indi-
viduals are left with unfinished business, which can be manifested in unexpressed
feelings such as resentment, rage, hatred, pain, anxiety, grief, guilt, and abandon-
ment. Unacknowledged feelings create unnecessary emotional debris that clutters
present-centered awareness. Because the feelings are not fully experienced in aware-
ness, they linger in the background and are carried into present life in ways that
interfere with effective contact with oneself and others: “These incomplete direc-
tions do seek completion and when they get powerful enough, the individual is beset
with preoccupation, compulsive behavior, wariness, oppressive energy and much self-
defeating behavior” (Polster & Polster, 1973, p. 36). Unfinished business persists until
the individual faces and deals with the unexpressed feelings. The effects of unfinished
business often show up in some blockage within the body, and the therapist’s task is
to assist clients in exploring these bodily expressions. Gestalt therapists emphasize
paying attention to the bodily experience on the assumption that if feelings are unex-
pressed they tend to result in some physical sensations or problems.
The impasse, or stuck point, occurs when external support is not available or
the customary way of being does not work. The therapist’s task is to accompany
clients in experiencing the impasse without rescuing or frustrating them. The coun-
selor assists clients by providing situations that encourage them to fully experience
their condition of being stuck. By completely experiencing the impasse, they are
able to get into contact with their frustrations and accept whatever is rather than
wishing they were different. Gestalt therapy is based on the notion that individuals
have a striving toward actualization and growth and that if they accept all aspects
of themselves without judging these dimensions they can begin to think, feel, and
act differently.
Energy and Blocks to Energy
When energy is blocked, in may result in unfinished business (Conyne, 2015). In
Gestalt therapy special attention is given to where energy is located, how it is used,
and how it can be blocked. Blocked energy is another form of defensive behavior. It
can be manifested by tension in some part of the body, by posture, by keeping one’s
body tight and closed, by not breathing deeply, by looking away from people when
speaking to avoid contact, by choking off sensations, by numbing feelings, and by
speaking with a restricted voice, to mention only a few.
Clients may not be aware of their energy or where it is located, and they may
experience it in a negative way. One of the tasks of the therapist is to help clients
find the focus of interrupted energy, identify the ways in which they are blocking
energy, and transform this blocked energy into more adaptive behaviors. Clients can
be encouraged to recognize how their resistance is being expressed in their body.
Rather than trying to rid themselves of certain bodily symptoms, clients can be
encouraged to delve fully into tension states and bodily symptoms. For example,
by allowing themselves to exaggerate their tight mouth and shaking legs, they can
discover for themselves how they are diverting energy and keeping themselves from
a full expression of aliveness.
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206 C H A P T E R E I G H T
The Therapeutic Process
Therapeutic Goals
Gestalt therapy does not ascribe to a “goal-oriented” methodology per se, but ther-
apists clearly attend to a basic goal—namely, assisting the client to attain greater
awareness, and with it, greater choice. Awareness includes knowing the environ-
ment, knowing oneself, accepting oneself, and being able to make contact. Increased
and enriched awareness, by itself, is seen as curative. Without awareness clients do
not possess the tools for personality change. With awareness they have the capacity
to face, accept, and integrate denied parts as well as to fully experience their sub-
jectivity. Through becoming aware of these denied parts and working toward own-
ing their experience, clients can become integrated, or whole. When clients stay with
their awareness, important unfinished business will emerge and can be dealt with
in therapy. The Gestalt approach helps clients note their own awareness process so
that they can be responsible and can selectively and discriminatingly make choices.
Awareness emerges within the context of a genuine meeting (contact) between cli-
ent and therapist.
The existential view (see Chapter 6) is that we are continually engaged in a pro-
cess of remaking and discovering ourselves. We do not have a static identity, but
discover new facets of our being as we face new challenges. Gestalt therapy is basi-
cally an existential encounter out of which clients tend to move in certain directions.
Through a creative involvement in Gestalt process, Zinker (1978) expects clients will
do the following:
�� Move toward increased awareness of themselves
�� Gradually assume ownership of their experience (as opposed to making
others responsible for what they are thinking, feeling, and doing)
�� Develop skills and acquire values that will allow them to satisfy their
needs without violating the rights of others
�� Become more aware of all of their senses
�� Learn to accept responsibility for what they do, including accepting the
consequences of their actions
�� Be able to ask for and get help from others and be able to give to others
Therapist’s Function and Role
The therapist’s job is to invite clients into an active partnership where they can learn
about themselves by adopting an experimental attitude toward life in which they
try out new behaviors and notice what happens (Perls, Hefferline, & Goodman,
1951). Gestalt therapists use active methods and personal engagement with clients
to increase their awareness, freedom, and self-direction rather than directing them
toward preset goals (Yontef & Jacobs, 2014).
Contemporary Gestalt practitioners view clients as the experts on their own
experience and encourage them to attend to their sensory awareness in the present
moment. Gestalt therapists value self-discovery and assume that clients can discover
for themselves the ways in which they block or interrupt their awareness and experi-
ence (Watson, Goldman, & Greenberg, 2011). Yontef (1993) stresses that although
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G E s TA lT T H E R A P y 207
the therapist functions as a guide and a catalyst, presents experiments, and shares
observations, the basic work of therapy is done by the client. Yontef maintains
that the therapist’s task is to create a climate in which clients are likely to try out
new ways of being and behaving. Gestalt therapists do not force change on clients
through confrontation. Instead, they work within a context of I/Thou dialogue in a
here-and-now framework.
An important function of Gestalt therapists is paying attention to clients’ body
language. These nonverbal cues provide rich information as they often represent
feelings of which the client is unaware. The therapist needs to be alert for gaps in
attention and awareness and for incongruities between verbalizations and what cli-
ents are doing with their bodies. Therapists might direct clients to speak for and
become their gestures or body parts by asking, “What do your eyes say?” “If your
hands could speak at this moment, what would they say?” “Can you carry on a con-
versation between your right and left hands?” Clients may verbally express anger and
at the same time smile. Or they may say they are in pain and at the same time laugh.
Therapists can ask clients to become aware of what their laughter might mean.
Laughter may mask feelings of anger or pain, and therapists can facilitate clients’
work in discovering what it could mean for them.
In addition to calling attention to clients’ nonverbal language, the Gestalt thera-
pist places emphasis on the relationship between language patterns and personal-
ity. Clients’ speech patterns are often an expression of their feelings, thoughts, and
attitudes. The Gestalt approach focuses on overt speaking habits as a way to increase
clients’ awareness of themselves, especially by asking them to notice whether their
words are congruent with what they are experiencing or instead are distancing them
from their emotions.
Language can both describe and conceal. By focusing on language, clients are
able to increase their awareness of what they are experiencing in the present moment
and of how they are avoiding coming into contact with this here-and-now experi-
ence. Here are some examples of the aspects of language that Gestalt therapists
might focus on:
�� “It” talk. When clients say “it” instead of “I,” they are using depersonal-
izing language. The counselor may ask them to substitute personal pro-
nouns for impersonal ones so that they will assume an increased sense
of responsibility. For example, if a client says, “It is difficult to make
friends,” he could be asked to restate this by making an “I” statement:
“I have trouble making friends.”
�� “You” talk. Global and impersonal language tends to keep the person hid-
den. The therapist often points out generalized uses of “you” and invites
the client to experiment with substituting “I” when this is what is meant.
�� Questions. Questions have a tendency to keep the questioner hidden,
safe, and unknown. Gestalt therapists often ask clients to experiment
with changing their questions into statements. In making personal
statements, clients begin to assume responsibility for what they say.
They may become aware of how they are keeping themselves mysteri-
ous through a barrage of questions and how this serves to prevent them
from making declarations that express themselves.
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208 C H A P T E R E I G H T
�� Language that denies power. Some clients have a tendency to deny their
personal power by adding qualifiers or disclaimers to their statements.
The therapist may also point out to clients how certain qualifiers sub-
tract from their effectiveness. Experimenting with omitting qualifiers
such as “maybe,” “perhaps,” “sort of,” “I guess,” “possibly,” and “I sup-
pose” can help clients change ambivalent messages into clear and direct
statements. Likewise, when clients say “I can’t,” they are really implying
“I won’t.” Encouraging clients to substitute “won’t” for “can’t” often
assists them in owning and accepting their power by taking responsi-
bility for their decisions. The therapist must be careful in intervening
so that clients do not feel that everything they say is subject to scru-
tiny. The therapist hopes to foster awareness of what is really being
expressed through words, not to scrutinize behavior.
�� Listening to clients’ metaphors. In his workshops, Erv Polster (1995)
emphasizes the importance of a therapist learning how to listen to the
metaphors of clients. By tuning into metaphors, the therapist gets rich
clues to clients’ internal struggles. Examples of metaphors that can be
amplified include client statements such as “It’s hard for me to spill
my guts in here.” “At times I feel that I don’t have a leg to stand on.” “I
feel like I have a hole in my soul.” “I need to be prepared in case some-
one blasts me.” “I felt ripped to shreds after you confronted me last
week.” “After this session, I feel as though I’ve been put through a meat
grinder.” Beneath the metaphor may lie a suppressed internal dialogue
that represents critical unfinished business or reactions to a present
interaction. For example, to the client who says she feels that she has
been put through a meat grinder, the therapist could ask: “What is your
experience of being ground meat?” or “Who is doing the grinding?” It is
essential to encourage this client to say more about what she is experi-
encing. The art of therapy consists of assisting clients in translating the
meaning of their metaphors so that they can be dealt with in therapy.
�� Listening for language that uncovers a story. Polster (1995) also teaches the
value of what he calls “fleshing out a flash.” He reports that clients
often use language that is elusive yet gives significant clues to a story
that illustrates their life struggles. Effective therapists learn to pick out
a small part of what someone says and then to focus on and develop
this element. Clients are likely to slide over pregnant phrases, but the
alert therapist can ask questions that will help them flesh out their
story line. It is essential for therapists to pay attention to what is fasci-
nating about the person who is sitting before them and get that person
to tell a story.
In a workshop I observed Erv Polster’s magnificent style in challenging a person
(Joe) who had volunteered for a demonstration of an individual session. Although
Joe had a fascinating story to reveal about a particular facet of his life, he was pre-
senting himself in a lifeless manner, and the energy was going flat. Eventually, Polster
asked him, “Are you keeping my interest right now? Does it matter to you whether I
am engaged with you?” Joe looked shocked, but he soon got the point. He accepted
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G E s TA lT T H E R A P y 209
Polster’s challenge to make sure that he not only kept the therapist interested but
also presented himself in a way to keep those in the audience interested. It was clear
that Polster was directing Joe’s attention to a process of how he was expressing his
feelings and life experiences rather than being concerned with what he was talking
about.
Polster believes storytelling is not always a form of resistance. Instead, it can
be the heart of the therapeutic process. He maintains that people are storytelling
beings. The therapist’s task is to assist clients in telling their story in a lively way.
Polster (1987b) believes many people come to therapy to change the titles of their
stories rather than to transform their life stories.
Client’s Experience in Therapy
The general orientation of Gestalt therapy is toward dialogue, an engagement
between people who each bring their unique experiences to that meeting (Yontef
& Schulz, 2013). Traditional Gestalt therapists assumed that clients must be con-
fronted about how they avoid accepting responsibility, but the dialogic attitude
that characterizes contemporary Gestalt therapy creates the ground for a meeting
place between client and therapist. Other issues that can become the focal point of
therapy include the client–therapist relationship and the similarities in the ways
clients relate to the therapist and to others in their environment.
Gestalt therapists do not make interpretations that explain the dynamics of an
individual’s behavior or tell a client why he or she is acting in a certain way because
they are not the experts on the client’s experience. Clients in Gestalt therapy are
active participants who make their own interpretations and meanings. It is they
who increase awareness and decide what they will or will not do with their personal
meaning.
Miriam Polster (1987) described a three-stage integration sequence that charac-
terizes client growth in therapy. The first part of this sequence consists of discovery.
Clients are likely to reach a new realization about themselves or to acquire a novel
view of an old situation, or they may take a new look at some significant person in
their lives. Such discoveries often come as a surprise to them.
The second stage of the integration sequence is accommodation, which involves
clients’ recognizing that they have a choice. Clients begin by trying out new behav-
iors in the supportive environment of the therapy office, and then they expand their
awareness of the world. Making new choices is often done awkwardly, but with ther-
apeutic support clients can gain skill in coping with difficult situations. Clients are
likely to participate in out-of-office experiments, which can be discussed in the next
therapy session.
The third stage of the integration sequence is assimilation, which involves clients’
learning how to influence their environment. At this phase clients feel capable of
dealing with the surprises they encounter in everyday living. They are now begin-
ning to do more than passively accept the environment. Behavior at this stage may
include taking a stand on a critical issue. Eventually, clients develop confidence in
their ability to improve and improvise. Improvisation is the confidence that comes
from knowledge and skills. Clients are able to make choices that will result in getting
what they want. The therapist points out that something has been accomplished
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210 C H A P T E R E I G H T
and acknowledges the changes that have taken place within the client. At this phase
clients have learned what they can do to maximize their chances of getting what is
needed from their environment.
Relationship Between Therapist and Client
As an existential brand of therapy, Gestalt practice involves a person-to-person rela-
tionship between therapist and client. Therapists are responsible for the quality of
their presence, for knowing themselves and the client, and for remaining open to the
client. They are also responsible for establishing and maintaining a therapeutic atmo-
sphere that will foster a spirit of work on the client’s part. It is important that thera-
pists allow themselves to be affected by their clients and that they actively share
their own present perceptions and experiences as they encounter clients in the here
and now. However, therapists need to be thoughtful about when and what to share.
When a difficulty in a client’s life is being enacted in the therapeutic relationship,
the therapist invites the client to explore this issue (Wheeler & Axelsson, 2015).
Gestalt therapists not only allow their clients to be who they are but also remain
themselves and do not get lost in a role. Therapists are expected to encounter clients
with honest and immediate reactions, and therapists share their personal experi-
ence and stories in relevant and appropriate ways. Further, they give feedback that
allows clients to develop an awareness of what they are actually doing. Brown (2007)
suggests that therapists share their reactions with clients, yet she also stresses the
importance of demonstrating an attitude of respect, acceptance, present-centeredness,
and presence.
A number of writers have given central importance to the I/Thou relationship
and the quality of the therapist’s presence, as opposed to emphasizing technical
skills. They warn of the dangers of becoming technique-bound and losing sight of
their own being as they engage with the client. Contemporary relational Gestalt
therapy has moved beyond earlier (traditional) therapeutic practices. Creating a
relationship (or alliance) is not a prelude to therapy but is at the heart of Gestalt
therapy. The therapist’s attitudes and behavior and the relationship that is estab-
lished are what really count (Brown, 2007; Frew, 2013; Melnick & Nevis, 2005; E.
Polster, 1987a, 1987b; M. Polster, 1987; Resnick, 2015; Wheeler & Axelsson, 2015;
Yontef & Jacobs, 2014).
Many contemporary Gestalt therapists place increasing emphasis on factors
such as presence, authentic dialogue, gentleness, more direct self-expression by
the therapist, decreased use of stereotypic exercises, and greater trust in the client’s
experiencing. Laura Perls (1976) stressed the notion that the person of the thera-
pist is more important than using techniques. She says, “There are as many styles
as there are therapists and clients who discover themselves and each other and
together invent their relationship” (p. 223). A current trend in Gestalt practice is
toward greater emphasis on the client–therapist relationship, and therapists who
operate from this orientation are able to establish a present-centered, nonjudgmen-
tal dialogue that allows clients to deepen their awareness and to make contact with
another person (Jacobs, 1989; Wheeler & Axelsson, 2015).
Polster and Polster (1973) emphasize the importance of therapists knowing
themselves and being therapeutic instruments. Like artists who need to be in touch
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G E s TA lT T H E R A P y 211
with what they are painting, therapists are artistic participants in the creation of new
life. The Polsters implore therapists to use their own experiences as essential ingre-
dients in the therapy process. According to them, therapists are more than mere
responders or catalysts. If they are to make effective contact with clients, therapists
must be in tune with both their clients and themselves. Therapy is a two-way engage-
ment that changes both the client and the therapist. If therapists are not sensitively
tuned to their own qualities of tenderness, toughness, and compassion and to their
reactions to the client, they become technicians. Experiments should be aimed at
awareness, not at simple solutions to a client’s problem.
Application: Therapeutic Techniques and Procedures
The Experiment in Gestalt Therapy
Although the Gestalt approach is concerned with the obvious, its simplicity
should not be taken to mean that the therapist’s job is easy. Developing a variety
of interventions is simple, but employing these methods in a mechanical fashion
allows clients to continue inauthentic living. If clients are to become authen-
tic, they need contact with an authentic therapist. Gestalt therapy methodol-
ogy is tailored to the needs of clients, and experiments are typically presented in
an invitational manner. Dr. Jon Frew, a Gestalt therapist, demonstrates Gestalt
interventions applied to the case of Ruth in Case Approach to Counseling and Psycho-
therapy (Corey, 2013, chap. 6).
Before discussing the variety of Gestalt methods you could include in your rep-
ertoire of counseling procedures, it is helpful to differentiate between exercises (or
techniques) and experiments. exercises are ready-made techniques that are some-
times used to make something happen in a therapy session or to achieve a goal.
They can be catalysts for individual work or for promoting interaction among
members of a therapy group. experiments, in contrast, grow out of the interaction
between client and therapist, and they emerge within this dialogic process. They
can be considered the very cornerstone of experiential learning. Frew (2013) defines
the experiment “as a method that shifts the focus of counseling from talking about
a topic to an activity that will heighten the client’s awareness and understanding
through experience” (p. 238). According to Melnick and Nevis (2005), experiments
have been confused with techniques: “A technique is a performed experiment with
specific learning goals. . . . An experiment, on the other hand, flows directly from
psychotherapy theory and is crafted to fit the individual as he or she exists in the
here and now” (p. 108).
In Gestalt therapy, an experiment is an intervention and active technique that
facilitates the collaborative exploration of a client’s experience (Brownell, 2016;
Yontef & Schulz, 2013). Experiments give people a chance to be systematic in learn-
ing by doing and are best thought of as ways of exploring a client’s experiential
world. Clients explore their awareness process and discover how their thinking,
feeling, sensing, and behaving either works for them or does not (Yontef & Schulz,
2013). “The goal [of an experiment] is always learning—slowing down and deepen-
ing experience in the service of new understanding and new possibilities for more
flexible and effective response” (Wheeler & Axelsson, 2015, p. 40). Experiences are a
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212 C H A P T E R E I G H T
key part of the ongoing dialogue between client and therapist, not a method to fix
the client or to make the therapy process more exciting (Yontef & Schulz, 2013).
The experiment is fundamental to Gestalt therapy. Zinker (1978) sees therapy
sessions as a series of experiments, which are the avenues for clients to learn expe-
rientially. What is learned from an experiment is a surprise to both the client and
the therapist because an experiment is an intentional entry into novel experience
aimed at discovery. The most dynamic experiments emerge uniquely from the work
between client and therapist (Brownell, 2016). Gestalt experiments are a creative
adventure and a way in which clients can express themselves behaviorally. Experi-
ments are spontaneous, one-of-a-kind, and relevant to a particular moment and
a particular development of a figure-formation process. They are not designed to
achieve a particular goal but occur in the context of a moment-to-moment contact-
ing process between therapist and client. Polster (1995) indicates that experiments
are designed by the therapist and evolve from the theme already developing through
therapeutic engagement, such as the client’s report of needs, dreams, fantasies, and
body awareness. Experimentation is an attitude inherent in all Gestalt therapy; it is
a collaborative process with full participation of the client. Clients test an experi-
ment to determine what does and does not fit for them through their own awareness
(Yontef, 1993, 1995).
Miriam Polster (1987) says that an experiment is a way to bring out some kind
of internal conflict by making this struggle an actual process. It is aimed at facilitat-
ing a client’s ability to work through the stuck points of his or her life. Experiments
encourage spontaneity and inventiveness by bringing the possibilities for action
directly into the therapy session. By dramatizing or playing out problem situa-
tions or relationships in the relative safety of the therapy context, clients increase
their range of flexibility of behavior. According to M. Polster, Gestalt experiments
can take many forms: imagining a threatening future encounter; setting up a dia-
logue between a client and some significant person in his or her life; dramatizing
the memory of a painful event; reliving a particularly profound early experience in
the present; assuming the identity of one’s mother or father through role playing;
focusing on gestures, posture, and other nonverbal signs of inner expression; or
carrying on a dialogue between two conflicting aspects within the person. Clients
may experience the feelings associated with their conflicts as experiments bring
struggles to life by inviting clients to enact them in the present. It is crucial that
experiments be tailored to each individual and used in a timely and appropriate
manner; they also need to be carried out in a context that offers a balance between
support and risk. Sensitivity and careful attention on the therapist’s part are essen-
tial so that clients are “neither blasted into experiences that are too threatening nor
allowed to stay in safe but infertile territory” (M. Polster & Polster, 1990, p. 104).
If students-in-training limit their understanding of Gestalt therapy to simply
reading about the approach, Gestalt methods are likely to seem abstract and the
notion of experiments may seem strange. Asking clients to “become” an object in
one of their dreams, for instance, may seem silly and pointless. It is important for
counselors to personally experience the power of Gestalt experiments and to feel com-
fortable suggesting them to clients. In this regard, it can be most useful for trainees
to personally experience Gestalt methods as a client.
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G E s TA lT T H E R A P y 213
Preparing Clients for Gestalt Experiments
It is essential that counselors establish a relationship with their clients, so
that the clients will feel trusting enough to participate in the learning that can
result from Gestalt experiments. Clients will get more from Gestalt experiments
if they are oriented and prepared for them. Through a trusting relationship with
the therapist, clients are likely to recognize their resistance and allow themselves to
participate in these experiments.
If clients are to cooperate, counselors must avoid directing them in a com-
manding fashion to carry out an experiment. Typically, I ask clients if they are
willing to try out an experiment to see what they might learn from it. I also tell
clients that they can stop when they choose to, so the power is with them. Clients
at times say that they feel silly or self-conscious or that the task feels artificial or
unreal. At such times I am likely to respond by asking, “Are you willing to give
it a try and see what happens?” The way in which clients resist doing an experi-
ment reveals a great deal about their personality and their way of being in the
world. Gestalt therapists expect and respect the emergence of reluctance and
meet clients wherever they are. Gestalt experiments work best when the therapist
is respectful of the client’s cultural background and has a solid working alliance
with the person. Clients with a long history of containing their feelings may be
reluctant to participate in experiments that are likely to bring their emotions to
the surface.
Contemporary Gestalt therapy places much less emphasis on resistance than
the early version of Gestalt therapy. Although it is possible to look at “resistance to
awareness” and “resistance to contact,” the idea of resistance is viewed as unneces-
sary by some Gestalt therapists. Frew (2013) argues that the notion of resistance is
completely foreign to the theory and practice of Gestalt therapy and suggests that
resistance is a term frequently used for clients who are not doing what the therapist
wants them to do. Polster and Polster (1976) suggest that it is best for therapists to
observe what is actually and presently happening rather than trying to make some-
thing happen. This gets away from the notion that clients are resisting and thus
behaving wrongly. According to the Polsters, change occurs through contact and
awareness—one does not have to try to change. Maurer (2005) writes about “appre-
ciating resistance” as a creative adjustment to a situation rather than something to
overcome. Maurer claims that we need to respect resistance, take it seriously, and
view it as “the energy” and not “the enemy.”
It is well to remember that Gestalt experiments are designed to expand cli-
ents’ awareness and to help them try out new modes of behavior. Within the
safety of the therapeutic situation, clients are given opportunities and encour-
aged to “try on” a new behavior. An experimental attitude in the therapeutic
process involves the client’s input and allows what emerges between client and
therapist to guide the direction of the therapy (Yontef & Schulz, 2013). This
heightens the awareness of a particular aspect of functioning, which leads to
increased self-understanding (Breshgold, 1989; Yontef, 1995). Experiments
are only means to the end of helping people become more aware and making
changes they most desire.
LO4
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214 C H A P T E R E I G H T
The Role of Confrontation
Students are sometimes put off by their perception that a Gestalt counselor’s
style is direct and confrontational. I tell my students that it is a mistake to equate
the practice of any theory with its founder. In the workshops that Fritz Perls gave,
people often found him harshly confrontational and saw him as meeting his own
needs through showmanship. Yontef (1993) refers to the traditional Perlsian style as
a “boom-boom-boom therapy” characterized by theatrics, abrasive confrontation,
and intense catharsis. Yontef (1993, 1999) is critical of the anti-intellectual, individ-
ualistic, dramatic, and confrontational flavor that characterized traditional Gestalt
therapy in the “anything goes environment” of the 1960s and 1970s.
The contemporary practice of Gestalt therapy has progressed beyond this style.
According to Yontef (1999), contemporary relational Gestalt therapy has evolved
to include more support and increased kindness and compassion in therapy. This
approach “combines sustained empathic inquiry with crisp, clear, and relevant
awareness focusing” (p. 10). Perls practiced a highly confrontational approach as
a way to deal with avoidance, but this technique-focused style of working has given
way to a more dialogue-centered methodology today (Bowman, 2005; Frew, 2013;
Yontef & Jacobs, 2014; Yontef & Schulz, 2013).
In contemporary Gestalt therapy, confrontation is set up in a way that invites
clients to examine their behaviors, attitudes, and thoughts. Therapists can encour-
age clients to look at certain incongruities, especially gaps between their verbal and
nonverbal expression. Further, confrontation does not have to be aimed at weak-
nesses or negative traits; clients can be challenged to recognize how they are block-
ing their strengths.
Therapists who care enough to make demands on their clients are telling them,
in effect, that they could be in fuller contact with themselves and others. Ultimately,
however, clients must decide for themselves if they want to accept this invitation to
learn more about themselves. This caveat needs to be kept in mind with all of the
experiments that are to be described.
Gestalt Therapy Interventions
Exercises are preplanned activities that can be used to elicit emotion, pro-
duce action, or achieve a specific goal. Experiments, in contrast, are spontaneously
created to fit what is happening in the therapeutic process and can be useful tools
to help clients gain fuller awareness, experience internal conflicts, resolve incon-
sistencies and dichotomies, and work through impasses that prevent completion
of unfinished business (Conyne, 2015). Some therapists operate on the erroneous
assumption that the practice of Gestalt therapy consists of a bag of techniques that
define the therapy, but as Resnick (2015) states, techniques and exercises are the
least important part of Gestalt therapy.
The techniques described here neither define Gestalt therapy nor are they a nec-
essary part of Gestalt practice. When used at their best, these interventions fit the
therapeutic situation and highlight whatever the client is experiencing. The follow-
ing material is based on Levitsky and Perls (1970), with my own suggestions added
for implementing these methods.
LO5
LO6
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G E s TA lT T H E R A P y 215
The Internal Dialogue Exercise One goal of Gestalt therapy is to bring about
integrated functioning and acceptance of aspects of one’s personality that have been
disowned and denied. Gestalt therapists pay close attention to splits in personality
function. A main division is between the “top dog” and the “underdog,” and therapy
often focuses on the war between the two.
The top dog is righteous, authoritarian, moralistic, demanding, bossy, and
manipulative. This is the “critical parent” that badgers with “shoulds” and “oughts”
and manipulates with threats of catastrophe. The underdog manipulates by playing
the role of victim: by being defensive, apologetic, helpless, and weak and by feigning
powerlessness. This is the passive side, the one without responsibility, and the one
that finds excuses.
The top dog and the underdog are engaged in a constant struggle for control.
The struggle helps to explain why one’s resolutions and promises often go unful-
filled and why one’s procrastination persists. The tyrannical top dog demands that
one be thus-and-so, whereas the underdog defiantly plays the role of disobedient
child. As a result of this struggle for control, the individual becomes fragmented
into controller and controlled. The civil war between the two sides continues, with
both sides fighting for their existence.
The conflict between the two opposing poles in the personality is rooted in the
mechanism of introjection, which involves incorporating aspects of others, usu-
ally parents, into one’s personality. It is essential that clients become aware of their
introjects, especially the toxic introjects that poison the person and prevent person-
ality integration.
The Empty-Chair Technique Jacob Moreno, the founder of psychodrama, originated
the empty-chair technique, which was later incorporated into Gestalt therapy by
Perls. The empty chair is a vehicle for the technique of role reversal, which is useful
in bringing into consciousness the fantasies of what the “other” might be thinking
or feeling. Essentially, this is a role-playing technique in which all the parts are played
by the client. In this way the introjects can surface, and the client can experience the
conflict more fully. There are many applications for this technique. One of the more
important uses is to explore what another person in one’s social network might be
feeling, and what that person’s more realistic predicament might be.
Using two chairs, the therapist asks the client to sit in one chair and be fully the
top dog and then shift to the other chair and become the underdog. The dialogue
can continue between both sides of the client. The conflict can be resolved by the
client’s acceptance and integration of both sides. This exercise helps clients get in
touch with a feeling or a side of themselves that they may be denying; rather than
merely talking about a conflicted feeling, they intensify the feeling and experience
it fully. Further, by helping clients realize that the feeling is a very real part of them-
selves, the intervention discourages clients from disassociating the feeling. The goal
of this exercise is to promote a higher level of integration between the polarities and
conflicts that exist in everyone. The aim is not to rid oneself of certain traits but to
learn to accept and live with the polarities.
Future Projection Technique In future projection, an anticipated event is
brought into the present moment and acted out. This technique, often associated
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216 C H A P T E R E I G H T
with psychodrama, is designed to help clients express and clarify concerns they have
about the future. These concerns may include wishes and hopes, dreaded fears of
tomorrow, or goals that provide some direction to life. A client creates a future time
and place with selected people, brings this event into the present, and gets a new
perspective on a problem. Clients may act out either a version of the way they hope a
given situation will ideally unfold or their version of a feared outcome. Once clients
clarify their hopes for a particular outcome, they are in a better position to take
specific steps that will enable them to achieve the future they desire.
Making the Rounds Making the rounds is a Gestalt exercise that involves asking
a person in a group to go up to others in the group and either speak to or do
something with each person. The purpose is to confront, to risk, to disclose the self,
to experiment with new behavior, and to grow and change. I have experimented with
“making the rounds” when I sensed that a participant needed to face each person
in the group with some theme. For example, a group member might say: “I’ve been
sitting here for a long time wanting to participate but holding back because I’m
afraid of trusting people in here. And besides, I don’t think I’m worth the time of
the group anyway.” I might counter with “Are you willing to do something right
now to get yourself more invested and to begin to work on gaining trust and self-
confidence?” If the person answers affirmatively, my suggestion could well be, “Go
around to each person and finish this sentence: ‘I don’t trust you because . . . ’.” Any
number of exercises could be invented to help individuals involve themselves and
choose to work on the things that keep them frozen in fear.
Some other related illustrations and examples that I find appropriate for the
making-the-rounds intervention are reflected in clients’ comments such as these:
“I would like to reach out to people more often.” “Nobody in here seems to care
very much.” “I’d like to make contact with you, but I’m afraid of being rejected [or
accepted].” “It’s hard for me to accept compliments; I always discount good things
people say to me.”
The Reversal Exercise Certain symptoms and behaviors often represent reversals
of underlying or latent impulses. Thus, the therapist could ask a person who
claims to suffer from severe inhibitions and excessive timidity to play the role of an
exhibitionist. I remember a client in one of our therapy groups who had difficulty
being anything but sugary sweet. I asked her to reverse her typical style and be as
negative as she could be. The reversal worked well; soon she was playing her part
with real gusto, and later she was able to recognize and accept her “negative side” as
well as her “positive side.”
The theory underlying the reversal technique is that clients take the plunge into
the very thing that is fraught with anxiety and make contact with those parts of
themselves that have been submerged and denied. This technique can help clients
begin to accept certain personal attributes that they have tried to deny.
The Rehearsal Exercise Oftentimes we get stuck rehearsing silently to ourselves
so that we will gain acceptance. When it comes to the performance, we experience
stage fright, or anxiety, because we fear that we will not play our role well. Internal
rehearsal consumes much energy and frequently inhibits our spontaneity and
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G E s TA lT T H E R A P y 217
willingness to experiment with new behavior. When clients share their rehearsals
out loud with a therapist, they become more aware of the many preparatory means
they use in bolstering their social roles. They also become increasingly aware of
how they try to meet the expectations of others, of the degree to which they want
to be approved, accepted, and liked, and of the extent to which they go to attain
acceptance.
The Exaggeration Exercise One aim of Gestalt therapy is for clients to become
more aware of the subtle signals and cues they are sending through body language.
Movements, postures, and gestures may communicate significant meanings, yet
the cues may be incomplete. In this exercise the person is asked to exaggerate the
movement or gesture repeatedly, which usually intensifies the feeling attached to
the behavior and makes the inner meaning clearer. Some examples of behaviors
that lend themselves to the exaggeration technique are trembling (shaking hands,
legs), slouched posture and bent shoulders, clenched fists, tight frowning, facial
grimacing, crossed arms, and so forth. If a client reports that his or her legs are
shaking, the therapist may ask the client to stand up and exaggerate the shaking.
Then the therapist may ask the client to put words to the shaking limbs.
Staying With the Feeling Most people want to escape from fearful stimuli and
avoid unpleasant feelings. At key moments when clients refer to a feeling or a mood
that is unpleasant and from which they have a great desire to flee, the therapist
may urge clients to stay with their feeling and encourage them to go deeper into
the feeling or behavior they wish to avoid. Facing and experiencing feelings not
only takes courage but also is a mark of a willingness to endure the pain necessary
for unblocking and making way for newer levels of growth. A strong therapeutic
relationship built on trust and nonjudgmental acceptance fosters the safety needed
for clients to stay with these unpleasant feelings.
The Gestalt Approach to Dream Work In psychoanalysis dreams are interpreted,
intellectual insight is stressed, and free association is used to explore the unconscious
meanings of dreams. The Gestalt approach does not interpret and analyze dreams.
Instead, the intent is to bring dreams back to life and relive them as though they were
happening now. The dream is acted out in the present, and the dreamer becomes a
part of his or her dream. The suggested format for working with dreams includes
making a list of all the details of the dream, remembering each person, event, and
mood in it, and then becoming each of these parts by transforming oneself, acting
as fully as possible and inventing dialogue. Each part of the dream is assumed to
be a projection of the self, and the client creates scripts for encounters between the
various characters or parts. All of the different parts of a dream are expressions of
the client’s own contradictory and inconsistent sides. By engaging in a dialogue
between these opposing sides, the client gradually becomes more aware of the range
of his or her own feelings.
Perls’s concept of projection is central in his theory of dream formation; every
person and every object in the dream represents a projected aspect of the dreamer.
Perls (1969a) suggested that “we start with the impossible assumption that whatever
we believe we see in another person or in the world is nothing but a projection”
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218 C H A P T E R E I G H T
(p. 67). Recognizing the senses and understanding projections go hand in hand. Cli-
ents do not think about or analyze the dream but use it as a script and experiment
with the dialogue among the various parts of the dream. Because clients can act out
a fight between opposing sides, eventually they can appreciate and accept their inner
differences and integrate the opposing forces. Freud called the dream the royal road
to the unconscious, but to Perls dreams are the “royal road to integration” (p. 66).
According to Perls, the dream is the most spontaneous expression of the exis-
tence of the human being. It represents an unfinished situation, but every dream
also contains an existential message regarding oneself and one’s current struggle.
Everything can be found in dreams if all the parts are understood and assimilated;
dreams serve as an excellent way to discover personality voids by revealing missing
parts and clients’ methods of avoidance. Perls asserts that if dreams are properly
worked with, the existential message becomes clearer. If people do not remember
dreams, they may be refusing to face what is wrong with their life. At the very least,
the Gestalt counselor asks clients to talk to their missing dreams. For example, as
directed by her therapist, a client reported the following dream in the present tense,
as though she were still dreaming:
I have three monkeys in a cage. One big monkey and two little ones! I feel very
attached to these monkeys, although they are creating a lot of chaos in a cage that
is divided into three separate spaces. They are fighting with one another—the big
monkey is fighting with the little monkey. They are getting out of the cage, and
they are clinging onto me. I feel like pushing them away from me. I feel totally
overwhelmed by the chaos that they are creating around me. I turn to my mother
and tell her that I need help, that I can no longer handle these monkeys because
they are driving me crazy. I feel very sad and very tired, and I feel discouraged. I am
walking away from the cage, thinking that I really love these monkeys, yet I have
to get rid of them. I am telling myself that I am like everybody else. I get pets, and
then when things get rough, I want to get rid of them. I am trying very hard to
find a solution to keeping these monkeys and not allowing them to have such a
terrible effect on me. Before I wake up from my dream, I am making the decision
to put each monkey in a separate cage, and maybe that is the way to keep them.
The therapist then asked his client, Brenda, to “become” different parts of her
dream. Thus, she became the cage, and she became and had a dialogue with each
monkey, and then she became her mother, and so forth. One of the most power-
ful aspects of this technique was Brenda’s reporting her dream as though it were
still happening. She quickly perceived that her dream expressed a struggle she was
having with her husband and her two children. From her dialogue work, Brenda
discovered that she both appreciated and resented her family. She learned that she
needed to let them know about her feelings and that together they might work on
improving an intensely difficult lifestyle. She did not need an interpretation from
her therapist to understand the clear message of her dream.
Application to Group Counseling
As a therapeutic orientation based on field theory, Gestalt therapy is well
suited for a group context. A main goal of the Gestalt group is to heighten aware-
ness and self-regulation through interactions with one another and the group
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G E s TA lT T H E R A P y 219
itself (Conyne, 2015). Gestalt therapy encourages direct experience and actions as
opposed to merely talking about conflicts, problems, and feelings. If members have
anxieties pertaining to some future event, they can enact these future concerns in
the present. This here-and-now focus enlivens the group and assists members in
vividly exploring their concerns. Moving from talking about to action is often done
by the use of experiments in a group. Gestalt therapy employs a rich variety of inter-
ventions designed to intensify what group members are directly experiencing in the
present moment for the purpose of leading to increased awareness. Gestalt group
therapists attend to matters such as verbal and nonverbal language, postures, voice,
interpersonal interactions, and group processes (Conyne, 2015).
When one member is the focus of work, other members can be used to enhance
an individual’s work. Through the skill of linking, the group leader can bring a num-
ber of members into the exploration of a problem. I prefer an interactive style of
Gestalt group work and find that bringing in an interpersonal dimension maximizes
the therapeutic potency within the group. I do not like to introduce a technique to
promote something happening within a group; rather, I tend to invite members to
try out different behavioral styles as a way to heighten what a given member might
be experiencing at the moment. A group format provides a context for a great deal
of creativity in using interventions and designing experiments. These experiments
need to be tailored to each group member and used in a timely manner; they also
need to be carried out in a context that offers a balance between support and risk.
Experiments, at their best, evolve from what is going on within individual members
and what is happening in the group at the moment.
Although Gestalt group leaders encourage members to heighten their aware-
ness and attend to their interpersonal style of relating, leaders tend to take an active
role in creating experiments to help members tap their resources. Gestalt leaders are
actively engaged with the members, and leaders frequently engage in self-disclosure
as a way to enhance relationships and create a sense of mutuality within the group.
Gestalt leaders are especially concerned with awareness, contact, and experimenta-
tion (Yontef & Jacobs, 2014).
If members experience the group as being a safe place, they will be inclined to
move into the unknown and challenge themselves. To increase the chances that
members will benefit from Gestalt methods, group leaders need to communicate
the general purpose of these interventions and create an experimental climate. Lead-
ers are not trying to push an agenda; rather, members are free to try something new
and determine for themselves the outcomes of an experiment.
In training workshops in group counseling that Marianne Schneider Corey and
I conducted in Korea, the Gestalt approach was well accepted. Group members were
very open and willing to share themselves emotionally once a climate of safety was
created. Adopting the stance of phenomenological inquiry, we strive to avoid mak-
ing assumptions about the members of a group, and we are careful not to impose
our worldviews or values on them. Instead, we approach clients with respect, inter-
est, compassion, and presence. We work collaboratively with our clients to discover
how to best help them resolve the difficulties they experience internally, interper-
sonally, and in the context of their social environment. Although it is unrealistic to
think you need to know everything about different cultures, it is essential to bring an
attitude of respect and appreciation for differences to your work in diverse cultural
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220 C H A P T E R E I G H T
environments around the world. With these attitudes we found that we were able to
use many Gestalt interventions with Korean people in a group training context. In
some ways this is not surprising because in Korea there is an emphasis on collectiv-
istic values, and group work fits well into the Korean culture.
For a more detailed account of Gestalt therapy in groups, see Feder and Frew
(2008), Feder (2006), and Corey (2016, chap. 11).
Gestalt Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
There are opportunities to creatively use Gestalt methods with culturally
diverse populations if interventions are timed appropriately and used flexibly.
Frew (2013) notes that contemporary Gestalt therapy can be a useful and effective
approach with clients from diverse backgrounds because it takes the clients’ context
into account. One of the advantages of drawing on Gestalt experiments is that they
can be tailored to fit the unique way in which an individual perceives and interprets
his or her culture. Although most therapists have preconceptions, Gestalt thera-
pists strive to approach each client in an open way. By bracketing their own values,
Gestalt therapists remaining receptive to how clients’ realities differ from their own.
They do this by checking out their biases and views in dialogue with the client. This
is particularly important in working with individuals from other cultures.
Fernbacher and Plummer (2005) stress the importance of assisting Gestalt ther-
apy trainees in developing their own awareness and contend: “to undertake work
across cultures from a Gestalt perspective, it is essential that we explore our own
cultural selves . . . to make contact and encourage contact in and with others, we
need to know about ourselves” (p. 131).
Gestalt therapy is particularly effective in helping people integrate the polari-
ties within themselves. Many bicultural clients experience an ongoing struggle to
reconcile what appears to be diverse aspects of the two cultures in which they live.
In one of my weeklong groups, a dynamic piece of work was done by a woman with
European roots. Her struggle consisted of integrating her American side with her
experiences in Germany as a child. I suggested that she “bring her family into this
group” by talking to selected members in the group as though they were members of
her family. I invited her to imagine that she was 8 years old and that she could now
say to her parents and siblings things that she had never expressed. She was asked to
speak in German (because this was her primary language as a child). The combined
factors of her trust in the group, her willingness to re-create an early scene by reliving
it in the present moment, and her symbolic work with fantasy helped her achieve a
significant breakthrough. She was able to put a new ending to an old and unfinished
situation through her participation in this Gestalt experiment.
There are many opportunities to apply Gestalt experiments in creative ways
with diverse client populations. In cultures where indirect speech is the norm, non-
verbal behaviors may emphasize the unspoken content of verbal communication.
These clients may express themselves nonverbally more expressively than they do
with words. Gestalt therapists typically ask clients to focus on their gestures, facial
expressions, and what they are experiencing within their own body. They attempt to
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G E s TA lT T H E R A P y 221
fully understand the background of their clients’ culture. They are concerned about
which aspects of this background become central or figural for their clients and
what meaning clients place on these figures.
Shortcomings From a Diversity Perspective
To a greater extent than is true of most other approaches, there are some potential
problems in too quickly utilizing Gestalt experiments with some clients. Gestalt
methods can lead to a high level of intense feelings. This focus on affect has clear
limitations with those clients who have been culturally conditioned to be emotion-
ally reserved and to avoid openly expressing feelings. As mentioned earlier, some
individuals believe expressing feelings openly is a sign of weakness and a display
of one’s vulnerability. Therapists who operate on the assumption that catharsis is
necessary for any change to occur are likely to find certain clients becoming increas-
ingly reluctant to participate in experiments, and such clients may prematurely
terminate counseling. Other individuals have strong cultural injunctions prohibit-
ing them from directly expressing their emotions to their parents (such as “Never
show your parents that you are angry at them” or “Strive for peace and harmony,
and avoid conflicts”). I recall a client from India who was asked by his counselor to
“bring your father into the room.” The client was very reluctant to even symboli-
cally tell his father of his disappointment with their relationship. In his culture the
accepted way to deal with his father was to use his uncle as a go-between, and it was
considered highly inappropriate to express any negative feelings toward his father.
The client later said that he would have felt very guilty if he had symbolically told
his father what he sometimes thought and felt.
Gestalt therapists who have truly integrated their approach are sensitive enough
to practice in a flexible way. They consider the client’s cultural framework and are
able to adapt methods that are likely to be well received. They strive to help clients
experience themselves as fully as possible in the present, yet they are not rigidly bound
by dictates, nor do they routinely intervene whenever clients stray from the present.
Sensitively staying in contact with a client’s flow of experiencing entails the ability to
focus on the person and not on the mechanical use of techniques for a certain effect.
G estalt-oriented therapy focuses on the unfinished business Stan has with his parents, siblings, and
ex-wife. It appears that this unfinished business con-
sists mainly of feelings of resentment, and Stan turns
this resentment on himself. His present life situation
is spotlighted, but he may also need to reexperience
past feelings that could be interfering with his present
attempts to develop intimacy with others.
Although the focus is on Stan’s present behavior,
I guide him toward becoming aware of how he is car-
rying old baggage around and how it interferes with
his life today. My task is to assist him in re-creating
the context in which he made creative adjustments dur-
ing his childhood years that are no longer serving him
well. One of his cardinal introjections was, “I’m stupid,
and it would be better if I did not exist.”
Stan has been influenced by cultural messages
that he has accepted. I am interested in exploring his
cultural background, including his values and the
values characteristic of his culture. With this focus, I
assist Stan in identifying some of the following cul-
tural introjections: “Don’t talk about your family with
Gestalt Therapy Applied to the Case of Stan
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222 C H A P T E R E I G H T
Visit CengageBrain.com or watch the DVD for the
video program on Chapter 8, Theory and Practice of
Counseling and Psychotherapy: The Case of Stan and Lec-
turettes, session 6 (Gestalt therapy), for a demon-
stration of my approach to counseling stan from
this perspective. This session consists of stan
exploring one of his dreams in Gestalt fashion.
strangers, and don’t hang your dirty linen in public.”
“Don’t confront your parents because they deserve
respect.” “Don’t be too concerned about yourself.”
“Don’t show your vulnerabilities; hide your feel-
ings and weaknesses.” I invite Stan to examine those
introjections to assess their utility in his present cir-
cumstances. Although he can decide to retain those
aspects of his culture that he prizes, he is in a posi-
tion to modify or reject other cultural expectations. Of
course, this will be done when these issues emerge in
the foreground of his work.
I ask Stan to attend to what he becomes aware
of as the session begins: “What are you experiencing
as we are getting started today?” As I encourage Stan
to tune in to his present experience and selectively
make observations, a number of figures will emerge.
The goal is to focus on a figure of interest, one that
seems to hold the most energy or relevance for Stan.
When a figure is identified, my task is to deepen Stan’s
awareness of this thought, feeling, body sensation, or
insight through related experiments.
In typical Gestalt fashion, Stan deals with his pres-
ent struggles within the context of our relationship and
through experimentation. One possible experiment
would involve Stan becoming some of those individu-
als who told him how to think, feel, and behave as a
child. He can then become the child that he was and
respond to them from the place where he feels the most
confusion or pain. He experiences in new ways the feel-
ings that accompany his beliefs about himself, and he
comes to a deeper appreciation of how his feelings and
thoughts influence what he is doing today.
Stan has learned to hide his emotions rather than to
reveal them. Understanding this about him, we explore
his objections and concerns about “getting into feel-
ings.” The figure of interest now is his hesitation to expe-
rience or express emotion. Although I have no agenda
to get Stan to experience his feelings at this point, it is
important for him to increase his awareness of his reluc-
tance and to explore the meaning it holds for him.
If Stan decides that he wants to experience his
emotions rather than deny them, I ask: “What are you
aware of now having said what you did?” Stan says that
he can’t get his ex-wife out of his mind. He tells me
about the pain he feels over that relationship and how
he is frightened of getting involved again lest he be hurt
again. I continue to ask him to focus inward and get a
sense of what stands out for him at this very moment.
Stan replies: “I’m hurt and angry over all the pain that
I’ve allowed her to inflict on me.” I ask him to imagine
himself in earlier scenes with his ex-wife, as though the
painful situation were occurring in the here and now.
He symbolically relives and reexperiences the situation
by talking “directly” to his wife. By expressing his resent-
ments and hurts directly, Stan can begin to complete
some unfinished business that is interfering with his
current functioning. By participating in this experiment,
Stan is attaining more awareness of what he is now doing
and how he keeps himself locked into his past.
Questions for Reflection
�� How might you begin a session with Stan? Would
you suggest a direction he should pursue? Would
you wait for him to initiate work? Would you
ask him to continue from where he left off in the
previous session? Would you attend to whatever
theme or issue becomes figural to him?
�� What unfinished business can you identify in
Stan’s case? Does any of his experience of being
stuck remind you of yourself? How might you
work with Stan if he did bring up your own unfin-
ished business?
�� What kind of an experiment might you propose to
assist Stan in learning more about his hesitation
and reluctance to access and express his feelings?
�� Stan participated in an experiment to deal with
pain, resentment, and hurt over situations with
his ex-wife. How might you have worked with the
material Stan brought up? What kind of experi-
ment might you design? How would you decide
what kind of experiment to create?
�� How might you work with Stan’s cultural mes-
sages? Would you be able to respect his cultural
values and still encourage him to make an assess-
ment of some of the ways in which his culture is
affecting him today?
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G E s TA lT T H E R A P y 223
F rom a Gestalt perspective, I am interested in assist-ing Gwen in becoming more aware of herself as a
whole person in the here and now. My job is to hold
a mirror up and help her see herself with greater clar-
ity. I notice that Gwen has a slight limp as she walks
into my office. I ask about her limp, and Gwen tells
me she has had a great deal of pain in her left hip for
the past week. She explains that she has had trouble
with her hip before and that an MRI revealed negative
results. She goes on to say that it may be due to their
old mattress.
Therapist: Describe exactly where the pain is and what
the sensations feel like.
Gwen: Well, it feels uncomfortable in the crease of
my hip, and it’s a dull sore feeling.
Therapist: Describe the texture and color of the feel-
ing in your hip [asking her to make contact with her
bodily sensations].
Gwen: The pain is prickly, gray, and heavy [she begins to
connect with her body in the moment].
Therapist: What is that hip saying to you?
Gwen: This seems a bit strange, and I must admit I am
uncomfortable in giving my hip a voice.
Therapist: Although it may seem strange, I hope you
will give it a try to see what you might learn from
doing this. You can always stop when you think
that doing this is not helpful.
Gwen: OK, this is uncomfortable, but I will give it a
try [she has trust in our relationship]. This hip is moan-
ing and groaning!
Therapist: [An experiment may increase this connection.]
This may feel a little weird, but try to become
your hip and exaggerate how your hip is
feeling.
Gwen: [Begins to groan and whimper and tears come to
her eyes] I am so tired of the mountain of things I
have to do and never getting anywhere. I feel like
a fallen tree in the forest. I have fallen and no one
knows I am there and it is up to me to get up and
get going again.
In her daily life Gwen typically holds back her true
feelings. She is used to suppressing her irritations
and even her triumphs. Because she was frequently
ignored as a child, she feels that her thoughts and
emotions don’t really matter. Her role at work is to
solve problems, and at home she is the caretaker of
everyone. She rarely allows herself to be vulnerable
or fully human. Gwen sees herself as “in charge” and
seldom gives herself a moment to pause or catch her
breath.
Gwen: I know that basically I have a good life, I just
rush past the good stuff and forget to stop and re-
ally appreciate all the blessings. I can get so caught
up in what I have not done or what feels wrong, but
I can’t really complain. I know this hip is telling
me to slow down and enjoy more of my life. I don’t
have to be that fallen tree, I just need to ask for
the support I really need [her body has shifted and she
seems more relaxed in her chair].
Therapist: Bring your attention back to your hip.
What does it feel like now?
Gwen: It feels better now. It might be OK to slow
down. It might even be OK to take myself off of
some of these committees I am on. [Laughing]
Maybe my hip just needs to sit on a beach some-
where or at least slow down enough to have some
fun.
Therapist: It is important for you to stop for a mo-
ment and check in with your body. We hold our
emotions in our bodies. It’s important to take time
out to listen to what the sensations in our body
may be telling us.
As Gwen’s awareness increases, she is beginning
to realize some of her past ways of functioning are no
longer serving her and she can begin to do something
differently. It is my hope that Gwen can now see the
Gestalt Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a Gestalt therapy perspective and applying this model to Gwen.
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224 C H A P T E R E I G H T
Summary and Evaluation
Summary
Gestalt therapy is an experiential approach that stresses present awareness and
the quality of contact between the individual and the environment. The major
focus is on assisting the client to become aware of how behaviors that were once
part of creatively adjusting to past environments may be interfering with effec-
tive functioning and living in the present. The goal of the approach is, first and
foremost, to gain awareness.
Another therapeutic aim is to assist clients in exploring how they make con-
tact with elements of their environment. Change occurs through the heightened
awareness of “what is.” Because the Gestalt therapist has no agenda beyond
assisting clients to increase their awareness, there is no need to label a client’s
behavior as “resistance.” Instead, the therapist simply follows this new process
as it emerges. The therapist has faith that self-regulation is a naturally unfolding
process that does not have to be controlled (Breshgold, 1989). Awareness is a key
requirement for the restoration of self-regulation within the person’s environ-
ment (Resnick, 2015). With expanded awareness, clients are able to reconcile
polarities and dichotomies within themselves and proceed toward the reintegra-
tion of all aspects of themselves.
The therapist works with the client to identify the figures, or most salient
aspects of the individual–environmental field, as they emerge from the back-
ground. The Gestalt therapist believes each client is capable of self-regulating
if those figures are engaged and resolved so others can replace them. The role
of the Gestalt therapist is to help clients identify the most pressing issues,
needs, and interests and to design experiments that sharpen those figures
or that explore resistances to contact and awareness. Gestalt therapists are
encouraged to be appropriately self-disclosing, both about their here-and-
now reactions in the therapy hour and about their personal experiences, when
doing so will facilitate the therapeutic process (Yontef & Jacobs, 2014; Zahm,
1998).
connection between her unexpressed emotions and
the discomfort in her physical body. Gestalt therapy
gives Gwen the opportunity to focus on what is hap-
pening in her mind and body in the present moment
and on how an expression of emotions can lead to a
release in her physical body. Gestalt therapy can assist
Gwen in becoming more aware of herself as a whole
person. She can begin to challenge unfinished busi-
ness that has enabled her to experience success in her
career but has also resulted in her feeling overwhelmed
and filled with anxiety.
Questions for Reflection
�� What is the importance of exploring bodily sensa-
tions and physical symptoms with Gwen?
�� What therapeutic value do you see in asking Gwen
to “become her hip” and speak from it?
�� What are your reactions to the way that the thera-
pist introduced the idea to Gwen of carrying out
an experiment?
�� How might you have experienced doing this exper-
iment if you were in Gwen’s position?
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G E s TA lT T H E R A P y 225
Contributions of Gestalt Therapy
One contribution of Gestalt therapy is the exciting way in which the past is
dealt with in a lively manner by bringing relevant aspects into the present. Thera-
pists challenge clients in creative ways to become aware of and work with issues that
are obstructing current functioning. Further, paying attention to the obvious verbal
and nonverbal leads provided by clients is a useful way to approach a counseling ses-
sion. Through the skillful and sensitive use of Gestalt interventions, practitioners
can assist clients in heightening their present-centered awareness of what they are
thinking and feeling as well as what they are doing.
Gestalt methods bring conflicts and human struggles to life. Gestalt therapy is
a creative approach that uses experiments to move clients from talk to action and
experience. The creative and spontaneous use of active experiments is a pathway to
experiential learning. The focus is on growth and enhancement rather than being a
system of techniques to treat disorders, which reflects an early Gestalt motto, “You
don’t have to be sick to get better.” Clients are provided with a wide range of tools—
in the form of Gestalt experiments—for discovering new facets of themselves and
making decisions about changing their course of living.
The Gestalt approach to working with dreams is a unique pathway for people to
increase their awareness of key themes in their lives. By seeing each aspect of a dream
as a projection of themselves, clients are able to bring the dream to life, to interpret
its personal meaning, and to assume responsibility for it.
Gestalt therapy is a holistic approach that values each aspect of the individual’s
experience equally. Therapists allow the figure-formation process to guide them.
They do not approach clients with a preconceived set of biases or a set agenda.
Instead, they place emphasis on what occurs at the boundary between the individual
and the environment. Therapists do not try to move the client anywhere. The main
goal is to increase the client’s awareness of “what is.” Instead of trying to make some-
thing happen, the therapist’s role is assisting the client to increase awareness that
will allow reidentification with the part of the self from which he or she is alienated.
A key strength of Gestalt therapy is the attempt to integrate theory, practice,
and research. Although Gestalt therapy was light on empirical research for several
years, it has come more into vogue recently. Two books show potential for influ-
encing future research: Handbook for Theory, Research and Practice in Gestalt Therapy
(Brownell, 2008); and Becoming a Practitioner Researcher: A Gestalt Approach to Holistic
Inquiry (Barber, 2006). Strumpfel and Goldman (2002) note that both process and
outcome studies have advanced the theory and practice of Gestalt therapy, and they
summarize a number of significant findings based on outcome research:
�� Outcome studies have demonstrated Gestalt therapy to be equal to or
greater than other therapies for various disorders.
�� More recent studies have shown that Gestalt therapy has a beneficial
impact with personality disturbances, psychosomatic problems, and
substance addictions.
�� The effects of Gestalt therapy tend to be stable in follow-up studies one
to three years after termination of treatment.
�� Gestalt therapy has demonstrated effectiveness in treating a variety of
psychological disorders.
LO9
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226 C H A P T E R E I G H T
Limitations and Criticisms of Gestalt Therapy
Most of my criticisms of Gestalt therapy pertain to the traditional version, or the
style of Fritz Perls, which emphasized confrontation and de-emphasized the cogni-
tive factors of personality. This style of Gestalt therapy placed more attention on
using techniques to confront clients and getting them to experience their feelings.
Contemporary Gestalt therapy has come a long way, and more attention is being
given to theoretical instruction, theoretical exposition, and cognitive factors in gen-
eral (Yontef, 1993, 1995).
In Gestalt therapy clients clarify their thinking, explore beliefs, and put meaning
to experiences they are reliving in therapy. Clients assume an active role in partici-
pating in experiments, and they learn experientially. The emphasis is on facilitating
the clients’ own process of self-discovery and learning. This experiential and self-
directed learning process is based on the fundamental belief in organismic self-
regulation, which implies that clients arrive at their own truths through awareness
and improved contact with the environment. It seems to me, however, that clients
can engage in self-discovery and at the same time benefit from appropriate teaching
by the therapist. In addition to the benefits of experiential learning, clients can profit
from timely and useful information, and a psychoeducational focus can enhance the
learning process.
Contemporary Gestalt practice places a high value on the contact and dialogue
between therapist and client. For Gestalt therapy to be effective, the therapist must
have a high level of personal development. Being aware of one’s own needs and see-
ing that they do not interfere with the client’s process, being present in the moment,
and being willing to be nondefensive and self-revealing all demand a lot of the thera-
pist. There is a danger that therapists who are inadequately trained will be primarily
concerned with impressing clients.
Some Cautions Typically, Gestalt therapists are highly active and exhibit
sensitivity, timing, inventiveness, empathy, and respect for the client (Zinker,
1978). If therapists lack these qualities, their experiments can easily boomerang.
Some therapists employ Gestalt techniques without having a sound theoretical
rationale. Inept therapists may use powerful techniques to stir up feelings and
open up problems clients have kept from full awareness only to abandon the
clients once they have managed to have a dramatic catharsis. Such a failure to stay
with clients and help them work through what they have experienced and bring
some closure to the experience can be detrimental and could be considered as
unethical practice.
Effective practitioners of Gestalt therapy require a strong general clinical
background and training, not only in the theory and practice of Gestalt therapy
but also in personality theory, psychopathology, and knowledge of psychodynam-
ics (Yontef & Jacobs, 2014). Competent practitioners need to have engaged in
their own personal therapy and to have had advanced clinical training and super-
vised experience. Such therapists have learned to blend a phenomenological and
dialogic approach, which is inherently respectful to the client, with well-timed
experiments.
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G E s TA lT T H E R A P y 227
Self-Reflection and Discussion Questions
1. What are some advantages you can see in asking clients to bring any
problems or concerns they are experiencing into the here and now?
2. The ability of a therapist to be present during the therapy session is
central in Gestalt therapy practice. Can you think of some challenges
you are likely to face in being fully present for your clients? How can
you deal with these challenges?
3. What do you understand as the difference between an experiment and
an exercise or technique in Gestalt therapy?
4. Energy and blocks to energy are given prominence in Gestalt therapy.
What are some ideas you have for working with a client’s energy with-
out making interpretations for the client?
5. Imagine yourself as a client with a Gestalt therapist. What do you think
this experience would be like for you?
Where to Go From Here
Visit CengageBrain.com or watch the DVD for Integrative Counseling: The Case of Ruth
and Lecturettes, Session 7 (Emotive Focus in Counseling), in which I demonstrate how
I create experiments to heighten Ruth’s awareness. In my version of Gestalt work
with Ruth, I watch for cues from Ruth about what she is experiencing in the here
and now. By attending to what she is expressing both verbally and nonverbally, I am
able to suggest experiments during our sessions. In this particular session I employ a
Gestalt experiment, asking Ruth to talk to me as if I were her husband, John. During
this experiment, Ruth becomes quite emotional. You will see ways of exploring emo-
tional material and integrating this work into a cognitive framework as well.
Other Resources
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos demonstrating Gestalt therapy with adults and children. New arti-
cles, interviews, blogs, therapy cartoons, and videos are published monthly. DVDs
relevant to this chapter are available at www.psychotherapy.net and include the
following:
Oaklander, V. (2001). Gestalt Therapy with Children (Child Therapy with the
Experts Series)
Polster, I. (1997). Psychotherapy With the Unmotivated Patient
Training Programs and Associations
If you are interested in furthering your knowledge and skill in the area of Gestalt
therapy, you might consider pursuing Gestalt training, which would include attend-
ing workshops, seeking out personal therapy from a Gestalt therapist, and enrolling
in a Gestalt training program that would involve reading, practice, and supervision.
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228 C H A P T E R E I G H T
A comprehensive list of these resources, along with their websites is available in the
Appendixes of Woldt and Toman’s textbook (2005). Some of the most prominent
training programs and associations are listed here.
Gestalt Institute of Cleveland. Inc.
www.gestaltcleveland.org
Pacific Gestalt Institute
www.gestalttherapy.org
Gestalt Center for Psychotherapy and Training
www.gestaltnyc.org
Gestalt International Study Center
www.GISC.org
Gestalt Therapy Training Center Northwest
www.gttcnw.org
Gestalt Associates Training, Los Angeles
www.gatla.org
The most prominent professional associations for Gestalt therapy that hold
international conferences follow.
Association for the Advancement of Gestalt Therapy (AAGT)
www.AAGT.org
European Association for Gestalt Therapy (EAGT)
www.EAGT.org
Gestalt Australia New Zealand
www.ganz.org.au
Gestalt Review
www.gestaltreview.com
British Gestalt Journal
www.britishgestaltjournal.com
The Gestalt Directory includes information about Gestalt practitioners and train-
ing programs throughout the world and is available free of charge upon request to
the Center for Gestalt Development, Inc. The center also has many books, audio-
tapes, and videotapes available that deal with Gestalt practice.
The Center for Gestalt Development, Inc.
www.gestalt.org
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G E s TA lT T H E R A P y 229
Recommended Supplementary Readings
Gestalt Therapy Verbatim (Perls, 1969a) provides a
firsthand account of the way Fritz Perls worked. It
contains many verbatim transcripts of workshop
demonstrations.
Gestalt Therapy (Wheeler & Axelsson, 2015) offers
an excellent introduction to the theory, evolution,
research, and practice of Gestalt therapy. The book
is based on principles that encourage an active, pres-
ent-focused, relational stance on the therapist’s part.
Gestalt Therapy: History, Theory, and Practice (Woldt &
Toman, 2005) introduces the historical underpinnings
and key concepts of Gestalt therapy and features
applications of those concepts to therapeutic practice.
This is a significant publication in the field of Gestalt
therapy that contains pedagogical learning activities
and experiments, review questions, and photographs
of all contributors.
Gestalt Therapy Integrated: Contours of Theory and
Practice (E. Polster & Polster, 1973) is a classic in
the field and an excellent source for those who
want a more advanced and theoretical treatment
of this model.
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231
9Behavior Therapy
1. Identify the key figures associated
with the development of behavior
therapy.
2. Differentiate the four
developmental areas of behavior
therapy: classical conditioning,
operant conditioning, social
cognitive theory, and cognitive
behavior therapy.
3. Evaluate the central characteristics
and assumptions that unite the
diverse field of behavior therapy.
4. Understand how the function and
role of the therapist affects the
therapy process.
5. Describe the role of the client–
therapist relationship in the
behavioral approaches.
6. Identify the diverse array of
behavioral techniques and
procedures and how they fit
within the evidence-based practice
movement.
7. Describe the key concepts of
EMDR, its main applications, and
the effectiveness of this approach.
8. Describe the basic elements of
social skills training.
9. Understand and explain the main
steps involved in self-management
programs.
10. Identify the key concepts of the
four major approaches of the
mindfulness and acceptance-
based behavior therapies.
11. Examine the application of
behavioral principles and
techniques to brief interventions
and to group counseling.
12. Understand the advantages and
shortcomings of behavior therapy
in working with culturally diverse
clients.
13. Discuss the evaluation of
contemporary behavior therapy.
L e a r n i n g O b j e c t i v e s
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232 C H A P T E R N I N E
B. F. SKINNER (1904–1990) reported
that he was brought up in a warm, stable
family environment.* As he was grow-
ing up, Skinner was greatly interested
in building all sorts of things, an inter-
est that followed him throughout his
professional life. He received his PhD in
psychology from Harvard University in
1931 and eventually returned to Harvard
after teaching in several universities. He
had two daughters, one of whom is an
educational psychologist and the other
an artist.
Skinner was a prominent spokesperson for
behaviorism and can be considered the father of the
behavioral approach to psychology. Skinner cham-
pioned radical behaviorism, which places primary
emphasis on the effects of environment on behavior.
Skinner was also a determinist; he did not believe that
humans had free choice. He acknowledged that feel-
ings and thoughts exist, but he denied that they caused
our actions. Instead, he stressed the cause-and-effect
links between objective, observable environmental
conditions and behavior. Skinner maintained that
too much attention had been given to internal states
of mind and motives, which cannot be observed and
changed directly, and that too little focus had been
given to environmental factors that can
be directly observed and changed. He
was extremely interested in the concept
of reinforcement, which he applied to
his own life. For example, after working
for many hours, he would go into his
constructed cocoon (like a tent), put on
headphones, and listen to classical music
(Frank Dattilio, personal communica-
tion, September 24, 2010).
Most of Skinner’s work was of an
experimental nature in the laboratory,
but others have applied his ideas to teach-
ing, managing human problems, and social plan-
ning. Science and Human Behavior (Skinner, 1953) best
illustrates how Skinner thought behavioral concepts
could be applied to every domain of human behav-
ior. In Walden II (1948) Skinner describes a utopian
community in which his ideas, derived from the lab-
oratory, are applied to social issues. His 1971 book,
Beyond Freedom and Dignity, addressed the need for
drastic changes if our society was to survive. Skinner
believed that science and technology held the promise
for a better future.
B. F. Skinner
A
P
Im
ag
es
*This biography is based largely on Nye’s (2000) discussion of
B. F. Skinner’s radical behaviorism.
ALBERT BANDURA (b. 1925) was born
in a small town in northern Alberta,
Canada; he was the youngest of six chil-
dren in a family of Eastern European
descent.* Bandura spent his elemen-
tary and high school years in the one
school in town, which was short of
teachers and resources. These meager
educational resources proved to be an
asset rather than a liability as Bandura
early on learned the skills of self-direct-
edness, which would later become one
of his research themes. He earned his
PhD in clinical psychology from the University of
Iowa in 1952, and a year later he joined the faculty
at Stanford University. Bandura and his colleagues
did pioneering work in the area of social model-
ing and demonstrated that modeling is a powerful
process that explains diverse forms of learning (see
Bandura 1971a, 1971b; Bandura & Wal-
ters, 1963). In his research programs at
Stanford University, Bandura and his
colleagues explored social learning the-
ory and the prominent role of observa-
tional learning and social modeling in
human motivation, thought, and action.
By the mid-1980s Bandura had renamed
his theoretical approach social cogni-
tive theory, which shed light on how we
function as self-organizing, proactive,
self-reflective, and self-regulating beings
(see Bandura, 1986). This notion that we
are not simply reactive organisms shaped by environ-
mental forces or driven by inner impulses represented
a dramatic shift in the development of behavior ther-
apy. Bandura broadened the scope of behavior ther-
apy by exploring the inner cognitive-affective forces
that motivate human behavior.
Albert Bandura
Co
ur
te
sy
, D
r.
A
lb
er
t B
an
du
ra
, S
ta
nf
or
dU
ni
ve
rs
ity
,
Pa
lo
A
lto
, C
A
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B E H A v I o R T H E R A P y 233
Introduction
behavior therapy practitioners focus on directly observable behavior, current
determinants of behavior, learning experiences that promote change, tailoring
treatment strategies to individual clients, and rigorous assessment and evalua-
tion. Behavior therapy has been used to treat a wide range of psychological disor-
ders with specific client populations. Anxiety disorders, depression, posttraumatic
stress disorder, substance abuse, eating and weight disorders, sexual problems,
pain management, and hypertension have all been successfully treated using this
approach (Wilson, 2011). Behavioral procedures are used in the fields of develop-
mental disabilities, mental illness, education and special education, community
psychology, clinical psychology, rehabilitation, business, self-management, sports
psychology, health-related behaviors, medicine, and gerontology (Miltenberger,
2012; Wilson, 2011).
Historical Background
The behavioral approach had its origin in the 1950s and early 1960s, and it
was a radical departure from the dominant psychoanalytic perspective. The behav-
ior therapy movement differed from other therapeutic approaches in its application
of principles of classical and operant conditioning (which will be explained shortly)
to the treatment of a variety of problem behaviors. Today, it is difficult to find a con-
sensus on the definition of behavior therapy because the field has grown, become
more complex, and is marked by a diversity of views. Contemporary behavior ther-
apy is no longer limited to treatments based on traditional learning theory (Antony
& Roemer, 2011b), and it increasingly overlaps with other theoretical approaches
(Antony, 2014). Behavior therapists now use a variety of evidence-based techniques
in their practices, including cognitive therapy, social skills training, relaxation
LO1
There are some existential qualities inherent in
Bandura’s social cognitive theory. Bandura has pro-
duced a wealth of empirical evidence that demon-
strates the life choices we have in all aspects of our
lives. In Self-Efficacy: The Exercise of Control (Bandura,
1997), Bandura shows the comprehensive applica-
tions of his theory of self-efficacy to areas such as
human development, psychology, psychiatry, educa-
tion, medicine and health, athletics, business, social
and political change, and international affairs.
Bandura has concentrated on four areas of
research: (1) the power of psychological modeling
in shaping thought, emotion, and action; (2) the
mechanisms of human agency, or the ways peo-
ple influence their own motivation and behavior
through choice; (3) people’s perceptions of their
efficacy to exercise influence over the events that
affect their lives; and (4) how stress reactions and
depressions are caused. Bandura has created one of
the few mega-theories that still thrive in the 21st
century. He has shown that people need a sense of
self-efficacy and resilience to create a successful life
and to meet the inevitable obstacles and adversities
they encounter.
Bandura has written nine books, many of which
have been translated into various languages. In 2004
he received the Outstanding Lifetime Contribution
to Psychology Award from the American Psychologi-
cal Association. He still makes time for hiking, opera,
being with his family, and wine tasting in the Napa
and Sonoma valleys.
*This biography is based largely on Panjares’s (2004) discussion of
Bandura’s life and work.
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234 C H A P T E R N I N E
training, and mindfulness strategies—all discussed in this chapter. The following
historical sketch of behavior therapy is largely based on Spiegler (2016).
Traditional behavior therapy arose simultaneously in the United States, South
Africa, and Great Britain in the 1950s. In spite of harsh criticism and resistance from
psychoanalytic psychotherapists, the approach has survived. Its focus was on dem-
onstrating that behavioral conditioning techniques were effective and were a viable
alternative to psychoanalytic therapy.
In the 1960s Albert Bandura developed social learning theory, which combined
classical and operant conditioning with observational learning. Bandura made
cognition a legitimate focus for behavior therapy. During the 1960s a number of
cognitive behavioral approaches sprang up, which focus on cognitive representations of
the environment rather than on characteristics of the objective environment.
Contemporary behavior therapy emerged as a major force in psychology during
the 1970s, and it had a significant impact on education, psychology, psychotherapy,
psychiatry, and social work. Behavioral techniques were expanded to provide solu-
tions for business, industry, and child-rearing problems as well. Behavior therapy
techniques were viewed as the treatment of choice for many psychological problems.
The 1980s were characterized by a search for new horizons in concepts and methods
that went beyond traditional learning theory. Behavior therapists continued to subject
their methods to empirical scrutiny and to consider the impact of the practice of therapy
on both their clients and the larger society. Increased attention was given to the role of
emotions in therapeutic change, as well as to the role of biological factors in psychologi-
cal disorders. Two of the most significant developments in the field were (1) the contin-
ued emergence of cognitive behavior therapy as a major force and (2) the application of
behavioral techniques to the prevention and treatment of health-related disorders.
By the late 1990s the Association for Behavioral and Cognitive Therapies (ABCT)
(formerly known as the Association for Advancement of Behavior Therapy) claimed
a membership of about 4,500. Currently, ABCT includes approximately 6,000 men-
tal health professionals and students who are interested in empirically based behav-
ior therapy or cognitive behavior therapy. This name change and description reveals
the current thinking of integrating behavioral and cognitive therapies.
By the early 2000s, the behavioral tradition had broadened considerably, which
involved enlarging the scope of research and practice. This newest development,
sometimes known as the “third generation” or “third wave” of behavior therapy,
includes dialectical behavior therapy (DBT), mindfulness-based stress reduction
(MBSR), mindfulness-based cognitive therapy (MBCT), and acceptance and com-
mitment therapy (ACT). Behavior therapies are among the most widely used treat-
ment interventions for psychological and behavioral problems today (Antony, 2014).
visit CengageBrain.com or watch the DvD for the video program on Chapter 9, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Four Areas of Development
Contemporary behavior therapy can be understood by considering four
major areas of development: (1) classical conditioning, (2) operant conditioning,
(3) social-cognitive theory, and (4) cognitive behavior therapy.
LO2
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B E H A v I o R T H E R A P y 235
classical conditioning (respondent conditioning) refers to what happens prior
to learning that creates a response through pairing. A key figure in this area is Ivan
Pavlov who illustrated classical conditioning through experiments with dogs. Plac-
ing food in a dog’s mouth leads to salivation, which is respondent behavior. When
food is repeatedly presented with some originally neutral stimulus (something that
does not elicit a particular response), such as the sound of a bell, the dog will eventu-
ally salivate to the sound of the bell alone. However, if a bell is sounded repeatedly
but not paired again with food, the salivation response will eventually diminish and
become extinct. An example of a procedure that is based on the classical condition-
ing model is Joseph Wolpe’s systematic desensitization, which is described later in
this chapter. This technique illustrates how principles of learning derived from the
experimental laboratory can be applied clinically. Desensitization can be applied to
people who, through classical conditioning, developed an intense fear of flying after
having a frightening experience while flying.
Technically one can develop an intense fear of flying without having a frighten-
ing experience personally. For example, someone may see visual images of a plane
crashing off the coast of Brazil and develop a fear of flying even though that person
has never flown anywhere. Some researchers hold a different view and believe that
fear of flying may be due primarily to claustrophobia (Frank Dattilio, personal com-
munication, September 24, 2010).
Most of the significant responses we make in everyday life are examples of oper-
ant behaviors, such as reading, writing, driving a car, and eating with utensils. Oper-
ant conditioning involves a type of learning in which behaviors are influenced
mainly by the consequences that follow them. If the environmental changes brought
about by the behavior are reinforcing—that is, if they provide some reward to the
organism or eliminate aversive stimuli—the chances are increased that the behavior
will occur again. If the environmental changes produce no reinforcement or pro-
duce aversive stimuli, the chances are lessened that the behavior will recur. Posi-
tive and negative reinforcement, punishment, and extinction techniques, described
later in this chapter, illustrate how operant conditioning in applied settings can be
instrumental in developing prosocial and adaptive behaviors. Operant techniques
are used by behavioral practitioners in parent education programs and with weight
management programs.
The behaviorists of both the classical and operant conditioning models
excluded any reference to mediational concepts, such as the role of thinking pro-
cesses, attitudes, and values. This focus is perhaps due to a reaction against the
insight-oriented psychodynamic approaches. The social learning approach (or the
social-cognitive approach) developed by Albert Bandura and Richard Walters (1963) is
interactional, interdisciplinary, and multimodal (Bandura, 1977, 1982). Social-cognitive
theory involves a triadic reciprocal interaction among the environment, personal fac-
tors (beliefs, preferences, expectations, self-perceptions, and interpretations), and
individual behavior. In the social-cognitive approach, the environmental events on
behavior are mainly determined by cognitive processes governing how environmen-
tal influences are perceived by an individual and how these events are interpreted. A
basic assumption is that people are capable of self-directed behavior change and that
the person is the agent of change. For Bandura (1982, 1997), self-efficacy is the indi-
vidual’s belief or expectation that he or she can master a situation and bring about
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236 C H A P T E R N I N E
desired change. An example of social learning is ways people can develop effective
social skills after they are in contact with other people who effectively model inter-
personal skills.
cognitive behavior therapy (cbt) represents the mainstream of contempo-
rary behavior therapy and is a popular theoretical orientation among psychologists.
Cognitive behavioral therapy operates on the assumption that what people believe
influences how they act and feel. Since the early 1970s, the behavioral movement
has conceded a legitimate place to thinking, even to the extent of giving cognitive
factors a central role in understanding and treating emotional and behavioral prob-
lems. By the mid-1970s, cognitive behavior therapy had replaced behavior therapy as the
accepted designation, and the field began emphasizing the interaction among affec-
tive, behavioral, and cognitive dimensions.
Contemporary behavior therapy has much in common with cognitive behavior
therapy in which the mechanism of change is both cognitive (modifying thoughts
to change behaviors) and behavioral (altering external factors that lead to behavior
change; Follette & Callaghan, 2011). Social skills training, cognitive therapy, stress
management training, mindfulness, and acceptance-based practices all represent
the cognitive behavioral tradition. This chapter goes beyond the traditional behav-
ioral perspective and deals mainly with applied aspects of this model. Chapter 10 is
devoted to the cognitive behavioral approaches, which focus on changing clients’
cognitions (thoughts and beliefs) that maintain psychological problems.
Key Concepts
Current Trend in Behavior Therapy
Contemporary behavior therapy is grounded on a scientific view of human behavior
that accommodates a systematic and structured approach to counseling. The cur-
rent trend in behavior therapy is toward developing procedures that give control to
clients and thus increase their range of freedom. Behavior therapy aims to increase
people’s skills so that they have more options for responding. By overcoming debili-
tating behaviors that restrict choices, people are freer to select from possibilities
that were not available to them earlier, which increases individual freedom.
Basic Characteristics and Assumptions
Seven key characteristics define behavior therapy and its assumptions. One
defining characteristic is that behavior therapy is based on the principles and pro-
cedures of the scientific method. Experimentally derived principles of learning
are systematically applied to help people change their maladaptive behaviors. The
distinguishing characteristic of behavioral practitioners is their systematic adher-
ence to precision and to empirical evaluation. Behavior therapists state treatment
goals in concrete objective terms to make replication of their interventions possible.
Treatment goals are agreed upon by the client and the therapist. Throughout the
course of therapy, the therapist assesses problem behaviors and the conditions that
are maintaining them. Evaluation methods are used to discern the effectiveness
LO3
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B E H A v I o R T H E R A P y 237
of both assessment and treatment procedures. Therapeutic techniques employed
must have demonstrated effectiveness. In short, behavioral concepts and proce-
dures are stated explicitly, tested empirically within a conceptual framework, and
revised continually.
Behavior is not limited to overt actions a person engages in that we can observe,
however; behavior also includes internal processes such as cognitions, images,
beliefs, and emotions. The key characteristic of a behavior is that it is something
that can be operationally defined.
Behavior therapy deals with the client’s current problems and the factors influ-
encing them today rather than analyzing possible historical determinants. Empha-
sis is on specific factors that influence present functioning and what factors can be
used to modify performance. Behavior therapists look to the current environmental
events that maintain problem behaviors and help clients produce behavior change
by changing environmental events, through a process called functional assessment, or
what Wolpe (1990) referred to as a “behavioral analysis.” Behavior therapy recog-
nizes the importance of the individual, the individual’s environment, and the inter-
action between the person and the environment in facilitating change.
Clients involved in behavior therapy are expected to assume an active role by
engaging in specific actions to deal with their problems. Rather than simply talking
about their condition, clients are required to do something to bring about change.
Clients monitor their behaviors both during and outside the therapy sessions, learn
and practice coping skills, and role-play new behavior. Therapeutic tasks that clients
carry out in daily life, or homework assignments, are a basic part of this approach.
Behavior therapy is an action-oriented and an educational approach, and learning is
viewed as being at the core of therapy. Clients learn new and adaptive behaviors to
replace old and maladaptive behaviors.
This approach assumes that change can take place without insight into under-
lying dynamics and without understanding the origins of a psychological problem.
Behavior therapists operate on the premise that changes in behavior can occur prior
to or simultaneously with understanding of oneself, and that behavioral changes
may well lead to an increased level of self-understanding. Although it is true that
insight and understanding about the contingencies that exacerbate one’s problems
can supply motivation to change, knowing that one has a problem and knowing how
to change it are two different things (Martell, 2007).
Assessment is an ongoing process of observation and self-monitoring that
focuses on the current determinants of behavior, including identifying the prob-
lem and evaluating the change. Assessment informs the treatment process and
involves attending to the culture of clients as part of their social environments,
including social support networks relating to target behaviors. Critical to behav-
ioral approaches is the careful assessment and evaluation of the interventions used
to determine whether the behavior change resulted from the procedure.
Behavioral treatment interventions are individually tailored to specific prob-
lems experienced by the client. Several therapy techniques may be used to treat an
individual client’s problems. An important question that serves as a guide for this
choice is, “What treatment, by whom, is the most effective for this individual with that
specific problem and under which set of circumstances?” (Paul, 1967, p. 111).
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238 C H A P T E R N I N E
The Therapeutic Process
Therapeutic Goals
Goals occupy a place of central importance in behavior therapy. The general goals
of behavior therapy are to increase personal choice and to create new conditions for
learning. The client, with the help of the therapist, defines specific treatment goals
at the outset of the therapeutic process. Although assessment and treatment occur
together, a formal assessment takes place prior to treatment to determine behaviors
that are targets of change. Continual assessment throughout therapy determines
the degree to which identified goals are being met. It is important to devise a way to
measure progress toward goals based on empirical validation.
Contemporary behavior therapy stresses clients’ active role in formulating spe-
cific measurable goals. Goals must be clear, concrete, understood, and agreed on by
the client and the counselor. The counselor and client discuss the behaviors associ-
ated with the goals, the circumstances required for change, the nature of subgoals,
and a plan of action to work toward these goals. This process of determining thera-
peutic goals entails a negotiation between client and counselor that results in a con-
tract that guides the course of therapy. Behavior therapists and clients alter goals
throughout the therapeutic process as needed.
Therapist’s Function and Role
Behavior therapists conduct a thorough functional assessment (or behav-
ioral analysis) to identify the maintaining conditions by systematically gather-
ing information about situational antecedents (A), the dimensions of the problem
behavior (B), and the consequences (C) of the problem. This is known as the abc
model, and the goal of a functional assessment of a client’s behavior is to under-
stand the ABC sequence. This model of behavior suggests that behavior (B) is influ-
enced by some particular events that precede it, called antecedents (A), and by certain
events that follow it, called consequences (C). antecedent events cue or elicit a cer-
tain behavior. For example, with a client who has trouble going to sleep, listening to
a relaxation tape may serve as a cue for sleep induction. Turning off the lights
and removing the television from the bedroom may elicit sleep behaviors as well.
consequences are events that maintain a behavior in some way, either by increas-
ing or decreasing it. For example, a client may be more likely to return to counseling
after the counselor offers verbal praise or encouragement for having come in or for
having completed some homework. A client may be less likely to return if the coun-
selor is consistently late to sessions. In doing a behavioral assessment interview,
the therapist’s task is to identify the particular antecedent and consequent events
that influence, or are functionally related to, an individual’s behavior (Cormier,
Nurius, & Osborn, 2013).
Behaviorally oriented practitioners tend to be active and directive and to func-
tion as consultants and problem solvers. They rely heavily on empirical evidence
about the efficacy of the techniques they apply to particular problems. Behavioral
practitioners must have skills in selecting and applying treatment methods. They pay
close attention to the clues given by clients, and they are willing to follow their clini-
cal hunches. Behavior therapists use some techniques common to other approaches,
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B E H A v I o R T H E R A P y 239
such as summarizing, reflection, clarification, and open-ended questioning. Behav-
ior therapists are directive and often offer suggestions (Antony, 2014), but they may
perform these other functions as well (Miltenberger, 2012; Speigler, 2016):
�� The therapist strives to understand the function of client behaviors,
including how certain behaviors originated and how they are sustained.
With this understanding, the therapist formulates initial treatment
goals and designs and implements a treatment plan to accomplish
these goals.
�� The behavioral clinician uses strategies that have research support for
use with a particular kind of problem. These evidence-based strategies
promote generalization and maintenance of behavior change. A num-
ber of these strategies are described later in this chapter.
�� The clinician evaluates the success of the change plan by measuring
progress toward the goals throughout the duration of treatment. Out-
come measures are given to the client at the beginning of treatment
(called a baseline) and collected again periodically during and after
treatment to determine whether the strategy and treatment plan are
working. If not, adjustments are made in the strategies being used.
�� Follow-up assessments are conducted to evaluate whether the changes
are durable over time. Clients learn how to identify and cope with
potential setbacks and acquire behavioral and cognitive coping skills to
maintain changes and to prevent relapses.
Let’s examine how a behavior therapist might perform these functions. A cli-
ent comes to therapy to reduce her anxiety, which is preventing her from leaving the
house. The therapist is likely to begin with a specific analysis of the nature of her
anxiety. The therapist will ask how she experiences the anxiety of leaving her house,
including what she actually does in these situations. Systematically, the therapist gath-
ers information about this anxiety. When did the problem begin? In what situations
does it arise? What does she do at these times? What are her feelings and thoughts in
these situations? Who is present when she experiences anxiety? What does she do to
reduce the anxiety? How do her present fears interfere with living effectively? After this
assessment, specific behavioral goals are developed, and strategies such as relaxation
training, systematic desensitization, and exposure therapy are designed to help the
client reduce her anxiety to a manageable level. The therapist will get a commitment
from the client to work toward the specified goals, and the two of them will evaluate
the client’s progress toward meeting these goals throughout the duration of therapy.
For a description of applying a behavioral approach to the assessment and treat-
ment of an individual client, see Dr. Sherry Cormier’s behavioral interventions with
Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).
Client’s Experience in Therapy
One of the unique contributions of behavior therapy is that it provides the therapist
with a well-defined system of procedures to employ. Both therapist and client have
clearly defined roles, and the importance of client awareness and participation in
the therapeutic process is stressed. Behavior therapy is characterized by an active
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240 C H A P T E R N I N E
role for both therapist and client. A large part of the therapist’s role is to teach
concrete skills through the provision of instructions, modeling, and performance
feedback. The client engages in behavioral rehearsal with feedback until skills are
well learned and generally receives active homework assignments (such as self-
monitoring of problem behaviors) to complete between therapy sessions. Behavior
clinicians emphasize that changes clients make in therapy need to be translated into
their daily lives.
It is important for clients to be motivated to change, and they are expected to
cooperate in carrying out therapeutic activities, both during therapy sessions and in
everyday life. If clients are not involved in this way, the chances are slim that therapy
will be successful. Motivational interviewing (see Chapter 7), which honors the cli-
ent’s resistance in such a way that his or her motivation to change is increased over
time, is a behavioral strategy that has considerable empirical support (Miller & Roll-
nick, 2013).
Clients are encouraged to experiment for the purpose of enlarging their reper-
toire of adaptive behaviors. Counseling is not complete unless actions follow verbal-
izations. Behavioral practitioners make the assumption that it is only when the
transfer of changes is made from the sessions to everyday life that the effects of
therapy can be considered successful. Clients are as aware as the therapist is regard-
ing when the goals have been accomplished and when it is appropriate to terminate
treatment. It is clear that clients are expected to do more than merely gather insights;
they need to be willing to make changes and to continue implementing new behav-
ior once formal treatment has ended.
Relationship Between Therapist and Client
Behavioral practitioners have increasingly recognized the role of the thera-
peutic relationship and therapist behavior as critical factors related to the process
and outcome of treatment. As you will recall, the experiential therapies (existential
therapy, person-centered therapy, and Gestalt therapy) place primary emphasis on
the nature of the engagement between counselor and client. Today most behavioral
practitioners stress the value of establishing a collaborative working relationship
with clients but contend that warmth, empathy, authenticity, permissiveness, and
acceptance are necessary, but not sufficient, for behavior change to occur. The client–
therapist relationship is a foundation on which behavioral strategies are built to
help clients change in the direction they wish.
Application: Therapeutic Techniques and Procedures
A strength of the behavioral approaches is the development of specific thera-
peutic procedures that must be shown to be effective through objective means. The
results of behavioral interventions become clear because therapists receive continual
direct feedback from their clients. A hallmark of the behavioral approaches is that
the therapeutic techniques are empirically supported and evidence-based practice is
highly valued. Behavior therapy has been shown to be effective with many different
populations and for a wide array of disorders. Behavioral techniques can easily be
incorporated in other approaches as well.
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B E H A v I o R T H E R A P y 241
The therapeutic procedures used by behavior therapists are specifically designed
for a particular client rather than being randomly selected from a “bag of techniques.”
Therapists are often quite creative in their interventions. In the following sections I
describe a range of behavioral techniques available to the practitioner: applied behav-
ioral analysis, relaxation training, systematic desensitization, exposure therapies, eye
movement desensitization and reprocessing, social skills training, self-management
programs, multimodal therapy, and mindfulness and acceptance-based approaches.
These techniques do not encompass the full spectrum of behavioral procedures, but
they do represent a sample of the approaches used in the practice of contemporary
behavior therapy.
Applied Behavioral Analysis: Operant Conditioning Techniques
This section describes a few key principles of operant conditioning: positive rein-
forcement, negative reinforcement, extinction, positive punishment, and negative
punishment. For a detailed treatment of the wide range of operant conditioning
methods that are part of contemporary behavior modification, I recommend Milt-
enberger (2012) and Speigler (2016).
The most important contribution of applied behavior analysis is that it offers a
functional approach to understanding clients’ problems and addresses these prob-
lems by changing antecedents and consequences (the ABC model). Behaviorists
believe we respond in predictable ways because of the gains we experience (positive
reinforcement) or because of the need to escape or avoid unpleasant consequences
(negative reinforcement). Once clients’ goals have been assessed, specific behaviors
are targeted. The goal of reinforcement, whether positive or negative, is to increase
the target behavior. Positive reinforcement involves the addition of something of
value to the individual (such as praise, attention, money, or food) as a consequence
of certain behavior. The stimulus that follows the behavior is the positive reinforcer.
For example, a child earns excellent grades and is praised for studying by her parents.
If she values this praise, it is likely that she will have an investment in studying in the
future. When the goal of a program is to decrease or eliminate undesirable behav-
iors, positive reinforcement is often used to increase the frequency of more desirable
behaviors, which replace undesirable behaviors. In the above example, the parental
praise functions as the positive reinforcer and makes it more likely that the child
will maintain or even increase the frequency of studying and earning good grades.
Note that if a child did not value parental praise, this would not serve as a reinforcer.
The reinforcer is not defined by the form or substance that it takes but rather by the
function it serves: namely, to maintain or increase the frequency of a desired behavior.
negative reinforcement involves the escape from or the avoidance of aversive
(unpleasant) stimuli. The individual is motivated to exhibit a desired behavior to
avoid the unpleasant condition. For example, a friend of mine does not appreciate
waking up to the shrill sound of an alarm clock. She has trained herself to wake up
a few minutes before the alarm sounds to avoid the aversive stimulus of the alarm
buzzer.
Another operant method of changing behavior is extinction, which refers to
withholding reinforcement from a previously reinforced response. In applied set-
tings, extinction can be used for behaviors that have been maintained by positive
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242 C H A P T E R N I N E
reinforcement or negative reinforcement. For example, in the case of children who
display temper tantrums, parents often reinforce this behavior by the attention they
give to it. An approach to dealing with problematic behavior is to eliminate the con-
nection between a certain behavior (tantrums) and positive reinforcement (atten-
tion). In this example, if the parent ignores the child’s tantrum-related behaviors,
these behaviors will decrease or be eliminated through the extinction process. It should
be noted that extinction might well have negative side effects, such as anger and
aggression. Also note that during the extinction process unwanted behaviors may
increase temporarily before they begin to decrease. Extinction can reduce or elimi-
nate certain behaviors, but extinction does not replace those responses that have
been extinguished.
Another way behavior is controlled is through punishment, sometimes referred
to as aversive control, in which the consequences of a certain behavior result in a
decrease of that behavior. The goal of reinforcement is to increase target behavior, but
the goal of punishment is to decrease target behavior. Miltenberger (2012) describes
two kinds of punishment that may occur as a consequence of behavior: positive
punishment and negative punishment. In positive punishment an aversive stimu-
lus is added after the behavior to decrease the frequency of a behavior (such as a time-
out procedure with a child who is displaying misbehavior).
In negative punishment a reinforcing stimulus is removed following the behav-
ior to decrease the frequency of a target behavior (such as deducting money from a
worker’s salary for missing time at work, or taking television time away from a child
for misbehavior). In both kinds of punishment, the behavior is less likely to occur in
the future. These four operant procedures form the basis of behavior therapy pro-
grams for parent skills training and are also used in the self-management proce-
dures that are discussed later in this chapter.
Some behavioral practitioners are opposed to using aversive control or punish-
ment and recommended substituting positive reinforcement. The key principle in
the applied behavior analysis approach is to use the least aversive means possible
to change behavior, and positive reinforcement is known to be the most powerful
change agent. It is essential that reinforcement be used as a way to develop appropri-
ate behaviors that replace the behaviors that are suppressed.
Progressive Muscle Relaxation
Progressive muscle relaxation has become increasingly popular as a method of
teaching people to cope with the stresses produced by daily living. It is aimed at
achieving muscle and mental relaxation and is easily learned. After clients learn the
basics of relaxation procedures, it is essential that they practice these exercises daily
to obtain maximum results.
Jacobson (1938) is credited with initially developing the progressive muscle relax-
ation procedure. It has since been refined and modified, and relaxation procedures
are frequently used in combination with a number of other behavioral techniques.
Progressive muscle relaxation involves several components. Clients are given a set of
instructions that teaches them to relax. They assume a passive and relaxed position
in a quiet environment while alternately contracting and relaxing muscles. This pro-
gressive muscle relaxation is explicitly taught to the client by the therapist. Deep and
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B E H A v I o R T H E R A P y 243
regular breathing also is associated with producing relaxation. At the same time cli-
ents learn to mentally “let go,” perhaps by focusing on pleasant thoughts or images.
Clients are instructed to actually feel and experience the tension building up, to notice
their muscles getting tighter and study this tension, and to hold and fully experience
the tension. It is useful for clients to experience the difference between a tense and a
relaxed state. The client is then taught how to relax all the muscles while visualizing
the various parts of the body, with emphasis on the facial muscles. The arm muscles
are relaxed first, followed by the head, the neck and shoulders, the back, abdomen,
and thorax, and then the lower limbs. Relaxation becomes a well-learned response,
which can become a habitual pattern if practiced daily for about 25 minutes each day.
Relaxation procedures have been applied to a variety of clinical problems, either
as a separate technique or in conjunction with related methods. The most common
use has been with problems related to stress and anxiety, which are often mani-
fested in psychosomatic symptoms. Relaxation training has benefits in areas such
as preparing patients for surgery, teaching clients how to cope with chronic pain,
and reducing the frequency of migraine attacks (Ferguson & Sgambati, 2008). Some
other ailments for which progressive muscle relaxation is helpful include asthma,
headache, hypertension, insomnia, irritable bowel syndrome, and panic disorder
(Cormier et al., 2013).
For an exercise of the phases of the progressive muscle relaxation procedure that
you can apply to yourself, see Student Manual for Theory and Practice of Counseling and
Psychotherapy (Corey, 2017). For a more detailed discussion of progressive muscle
relaxation, see Ferguson and Sgambati (2008).
Systematic Desensitization
systematic desensitization, which is based on the principle of classical condition-
ing, is a basic behavioral procedure developed by Joseph Wolpe, one of the pioneers
of behavior therapy. Clients imagine successively more anxiety-arousing situations
at the same time that they engage in a behavior that competes with anxiety. Grad-
ually, or systematically, clients become less sensitive (desensitized) to the anxiety-
arousing situation. This procedure can be considered a form of exposure therapy
because clients are required to expose themselves to anxiety-arousing images as a
way to reduce anxiety.
Systematic desensitization is an empirically researched behavior therapy pro-
cedure that is time consuming, yet it is clearly effective and efficient in reducing
maladaptive anxiety and treating anxiety-related disorders, particularly in the area
of specific phobias (Cormier et al., 2013; Spiegler, 2016). Before implementing the
desensitization procedure, the therapist conducts an initial interview to identify spe-
cific information about the anxiety and to gather relevant background information
about the client. This interview, which may last several sessions, gives the therapist
a good understanding of who the client is. The therapist questions the client about
the particular circumstances that elicit the conditioned fears. For instance, under
what circumstances does the client feel anxious? If the client is anxious in social
situations, does the anxiety vary with the number of people present? Is the client
more anxious with women or men? The client is asked to begin a self-monitoring
process consisting of observing and recording situations during the week that elicit
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244 C H A P T E R N I N E
anxiety responses. Some therapists also administer a questionnaire to gather addi-
tional data about situations leading to anxiety.
If the decision is made to use the desensitization procedure, the therapist gives
the client a rationale for the procedure and briefly describes what is involved. A three-
step process is carried out in the desensitization process: (1) relaxation training, (2)
development of a graduated anxiety hierarchy, and (3) systematic desensitization
through presentation of hierarchy items while the client is in a deeply relaxed state
(Head & Gross, 2008).
The first step is progressive muscle relaxation, which were described earlier. The
therapist uses a quiet, soft, and pleasant voice to teach progressive muscular relax-
ation. The client is asked to create imagery of previously relaxing situations, such
as sitting by a lake or wandering through a beautiful field. It is important that the
client reach a state of calm and peacefulness. The client is instructed to practice
relaxation both as a part of the desensitization procedure and also outside the ses-
sion on a daily basis.
The therapist then works with the client to develop an anxiety hierarchy for each
of the identified areas. Stimuli that elicit anxiety in a particular area are analyzed,
such as rejection, jealousy, criticism, disapproval, or any phobia. The therapist con-
structs a ranked list of situations that elicit increasing degrees of anxiety or avoid-
ance. The hierarchy is arranged in order from the most anxiety-provoking situation
the client can imagine down to the situation that evokes the least anxiety. If it has
been determined that the client has anxiety related to fear of rejection, for exam-
ple, the highest anxiety-producing situation might be rejection by the spouse, next,
rejection by a close friend, and then rejection by a coworker. The least disturbing
situation might be a stranger’s indifference toward the client at a party.
Desensitization does not begin until several sessions after the initial interview has
been completed. Enough time is allowed for clients to learn relaxation in therapy
sessions, to practice it at home, and to construct their anxiety hierarchy. The desen-
sitization process begins with the client reaching complete relaxation with eyes
closed. A neutral scene is presented, and the client is asked to imagine it. If the client
remains relaxed, he or she is asked to imagine the least anxiety-arousing scene on
the hierarchy of situations that has been developed. The therapist moves progres-
sively up the hierarchy until the client signals that he or she is experiencing anxiety,
at which time the scene is terminated. Relaxation is then induced again, and the
scene is reintroduced again until little anxiety is experienced to it. Treatment ends
when the client is able to remain in a relaxed state while imagining the scene that
was formerly the most disturbing and anxiety-producing. The core of systematic
desensitization is repeated exposure in the imagination to anxiety-evoking situa-
tions without experiencing any negative consequences.
Homework and follow-up are essential components of successful desensiti-
zation. Clients are encouraged to practice selected relaxation procedures daily, at
which time they visualize scenes completed in the previous session. Gradually, they
can expose themselves to daily-life situations as a further way to manage their anxi-
eties. Clients tend to benefit the most when they have a variety of ways to cope with
anxiety-arousing situations that they can continue to use once therapy has ended
(Head & Gross, 2008).
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B E H A v I o R T H E R A P y 245
Systematic desensitization is among the most empirically supported therapy
methods available, especially for the treatment of anxiety. Not only does systematic
desensitization have a good track record in dealing with fears, it also has been used
to treat a variety of conditions including anger, asthmatic attacks, insomnia, motion
sickness, nightmares, and sleepwalking (Spiegler, 2016). Systematic desensitization
is often acceptable to clients because they are gradually and symbolically exposed to
anxiety-evoking situations. For a more detailed discussion of systematic desensitiza-
tion, see Head and Gross (2008), Speigler (2016), and Cormier et al. (2013).
In Vivo Exposure and Flooding
exposure therapies are designed to treat fears and other negative emotional responses
by introducing clients, under carefully controlled conditions, to the situations that
contributed to such problems. Exposure is a key process in treating a wide range
of problems associated with fear and anxiety. Exposure therapy involves systematic
confrontation with a feared stimulus, either through imagination or in vivo (live).
Imaginal exposure can be used prior to implementing in vivo exposure when a
client’s fears are so severe that the client is unable to participate in live exposure
(Hazlett-Stevens & Craske, 2008). Whatever route is used, exposure involves con-
tact by clients with what they find fearful. Desensitization is one type of exposure
therapy, but there are others. Two variations of traditional systematic desensitiza-
tion are in vivo exposure and flooding.
In Vivo Exposure In vivo exposure involves client exposure to the actual anxiety-
evoking events rather than simply imagining these situations. Live exposure has been
a cornerstone of behavior therapy for decades. Hazlett-Stevens and Craske (2008)
describe the key elements of the process of in vivo exposure. Typically, treatment
begins with a functional analysis of objects or situations a person avoids or fears.
Together, the therapist and the client generate a hierarchy of situations for the client
to encounter in ascending order of difficulty. In vivo exposure involves repeated
systematic exposure to fear items, beginning from the bottom of the hierarchy.
Clients engage in a brief, graduated series of exposures to feared events. As is the case
with systematic desensitization, clients learn responses incompatible with anxiety,
such as responses involving muscle relaxation. Clients are encouraged eventually to
experience their full fear response during exposure without engaging in avoidance.
Between therapy sessions, clients carry out self-directed exposure exercises. Clients’
progress with home practice is reviewed, and the therapist provides feedback on
how the client could deal with any difficulties encountered.
In some cases the therapist may accompany clients as they encounter feared sit-
uations. For example, a therapist could go with clients in an elevator if they had pho-
bias of using elevators. Of course, when this kind of out-of-office procedure is used,
matters of safety and appropriate ethical boundaries are always considered. People
who have extreme fears of certain animals could be exposed to these animals in real
life in a safe setting with a therapist. Self-managed in vivo exposure—a procedure in
which clients expose themselves to anxiety-evoking events on their own—is an alter-
native when it is not practical for a therapist to be with clients in real-life situations.
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246 C H A P T E R N I N E
Flooding Another form of exposure therapy is flooding, which refers to either in
vivo or imaginal exposure to anxiety-evoking stimuli for a prolonged period of time.
As is characteristic of all exposure therapies, even though the client experiences
anxiety during the exposure, the feared consequences do not occur.
in vivo flooding consists of intense and prolonged exposure to the actual anx-
iety-producing stimuli. Remaining exposed to feared stimuli for a prolonged period
without engaging in any anxiety-reducing behaviors allows the anxiety to decrease
on its own. Generally, highly fearful clients tend to curb their anxiety through the
use of maladaptive behaviors. In flooding, clients are prevented from engaging in
their usual maladaptive responses to anxiety-arousing situations. In vivo flooding
tends to reduce anxiety rapidly.
Imaginal flooding is based on similar principles and follows the same proce-
dures except the exposure occurs in the client’s imagination instead of in daily life.
An advantage of using imaginal flooding over in vivo flooding is that there are no
restrictions on the nature of the anxiety-arousing situations that can be treated. In
vivo exposure to actual traumatic events (airplane crash, rape, fire, flood) is often
not possible nor is it appropriate for both ethical and practical reasons. Imagi-
nal flooding can re-create the circumstances of the trauma in a way that does not
bring about adverse consequences to the client. Survivors of an airplane crash,
for example, may suffer from a range of debilitating symptoms. They are likely to
have nightmares and flashbacks to the disaster; they may avoid travel by air or have
anxiety about travel by any means; and they probably have a variety of distressing
symptoms such as guilt, anxiety, and depression. In vivo and imaginal exposure,
as well as flooding, are frequently used in the behavioral treatment for anxiety-
related disorders, specific phobia, social phobia, panic disorder, obsessive-compul-
sive disorder, posttraumatic stress disorder, and agoraphobia (Hazlett-Stevens &
Craske, 2008).
Because of the discomfort associated with prolonged and intense exposure,
some clients may not elect these exposure treatments. It is important for the
behavior therapist to work with the client to create motivation and readiness for
exposure. From an ethical perspective, clients should have adequate information
about prolonged and intense exposure therapy before agreeing to participate. It
is important that they understand that anxiety will be induced as a way to reduce
it. Clients need to make informed decisions after considering the pros and cons
of subjecting themselves to temporarily stressful aspects of treatment. Clients
should be informed that they can terminate exposure if they experience a high
level of anxiety.
The repeated success of exposure therapy in treating various disorders has
resulted in exposure being used as a part of most behavioral treatments for anxiety
disorders. Spiegler (2016) notes that exposure therapies are among the most potent
behavioral procedures available for anxiety-related disorders, and they can have
long-lasting effects. However, he adds, using exposure as a single treatment proce-
dure is not always sufficient. In cases involving severe and multifaceted disorders,
more than one behavioral intervention is often required. This is especially true with
posttraumatic stress disorders. Increasingly, imaginal and in vivo exposure are being
used in combination, which fits with the trend in behavior therapy to use treatment
packages as a way to enhance the effectiveness of therapy.
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B E H A v I o R T H E R A P y 247
Eye Movement Desensitization and Reprocessing
eye movement desensitization and reprocessing (EMDR) is a form of
exposure therapy that entails assessment and preparation, imaginal flooding, and
cognitive restructuring in the treatment of individuals with traumatic memories.
According to Shapiro and Solomon (2015), “EMDR is an integrative psychothera-
peutic approach that conceptualizes current mental health problems as emanating
from past experiences that have been maladaptively stored neurophysiologically as
unprocessed memories” (p. 303). The treatment involves the use of rapid, rhythmic
eye movements and other bilateral stimulation to treat clients who have experienced
traumatic stress. “EMDR comprises eight phases and a three-pronged methodology
to identify and process (1) memories of past adverse life experiences that underlie
present problems, (2) current situations that elicit disturbance, and (3) needed skills
that will provide positive memory templates to guide the client’s future behavior”
(p. 389). Developed by Francine Shapiro (2001), this therapeutic procedure draws
from a wide range of behavioral interventions. Designed to assist clients in dealing
with posttraumatic stress disorders, EMDR has been applied to a variety of popula-
tions including children, couples, sexual abuse victims, combat veterans, victims of
crime, rape survivors, accident victims, and individuals dealing with anxiety, panic,
depression, grief, addictions, and phobias.
Shapiro (2001) emphasizes the importance of the safety and welfare of the cli-
ent when using this approach. EMDR may appear simple to some, but the ethical
use of the procedure demands training and clinical supervision, as is true of using
exposure therapies in general. Because of the powerful reactions from clients, it is
essential that practitioners know how to safely and effectively manage these occur-
rences. Therapists should not use this procedure unless they receive proper training
and supervision from an authorized EMDR instructor. A more complete discussion
of this behavioral procedure can be found in Shapiro (2001, 2002a).
There is some controversy over whether the eye movements themselves create
change or whether cognitive techniques paired with eye movements act as change
agents. The role of lateral eye movements has yet to be clearly demonstrated, and
some evidence indicates that the eye movement component may not be integral
to the treatment (Prochaska & Norcross, 2014; Speigler, 2016). In a review of con-
trolled studies of EMDR in the treatment of trauma, Shapiro (2002b) reports that
EMDR clearly outperforms no treatment and achieves similar or superior results to
other methods of treating trauma. Shapiro and Solomon (2015) state that extensive
research has validated EMDR and randomized trials have confirmed that EMDR
is both effective and efficient. Twelve sessions with combat veterans resulted in the
elimination of PTSD diagnosis in more than 77% of the cases. When it comes to
the overall effectiveness of EMDR, Prochaska and Norcross (2014) note that “in
its 25-year history, EMDR has garnered more controlled research than any other
method used to treat trauma” (p. 210). In writing about the future of EMDR, Pro-
chaska and Norcross make several predictions: increasing numbers of practitioners
will receive training in EMDR; outcome research will shed light on EMDR’s effec-
tiveness compared to other current therapies for trauma; and further research and
practice will provide a sense of its effectiveness with disorders beyond posttraumatic
stress disorder.
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248 C H A P T E R N I N E
Social Skills Training
social skills training is a broad category that deals with an individual’s abil-
ity to interact effectively with others in various social situations; it is used to help
clients develop and achieve skills in interpersonal competence. Social skills involve
being able to communicate with others in a way that is both appropriate and effec-
tive. Individuals who experience psychosocial problems that are partly caused by
interpersonal difficulties are good candidates for social skills training. Typically,
social skills training involves various behavioral techniques such as psychoeduca-
tion, modeling, behavior rehearsal, and feedback (Antony & Roemer, 2011b). Social
skills training is effective in treating psychosocial problems by increasing clients’
interpersonal skills (Kress & Henry, 2015; Segrin, 2008). Some of the desirable
aspects of social skills training are that it has a very broad base of applicability and
that it can easily be tailored to suit the particular needs of individual clients.
Key elements of social skills training include assessment, direct instruction and
coaching, modeling, role playing, and homework assignments (Segrin 2008). Clients
learn information that they can apply to various interpersonal situations, and skills
are modeled for them so they can actually see how skills can be used. A key step
involves clients putting into action the information they are acquiring. Individu-
als actively practice desired behaviors through role playing. Feedback and reinforce-
ment assist clients in conceptualizing and using a new set of social skills that enables
them to communicate more effectively. If clients are able to correct their problem-
atic behaviors in practice situations, they can then apply these new skills in daily life
(Kress & Henry, 2015). A follow-up phase is critical for clients in establishing a range
of effective behaviors that can be applied to many social situations.
A few examples of evidence-based applications of social skills training include
alcohol/substance abuse, attention-deficit/hyperactivity disorder, bullying, social
anxiety, emotional and behavioral problems in children, behavioral treatment for
couples, and depression (Antony & Roemer, 2011b; Segrin, 2008). A popular varia-
tion of social skills training is anger management training, which is designed for indi-
viduals who have trouble with aggressive behavior.
Self-Management Programs and Self-Directed Behavior
For some time there has been a trend toward “giving psychology away.” This
involves psychologists being willing to share their knowledge so that “consumers”
can increasingly lead self-directed lives and not be dependent on experts to deal with
their problems. Psychologists who share this perspective are primarily concerned
with teaching people the skills they will need to manage their own lives effectively.
An advantage of self-management techniques is that treatment can be extended
to consumers in ways that cannot be done with traditional approaches to therapy.
Another advantage is that costs are minimal. Because clients have a direct role in
their own treatment, techniques aimed at self-change tend to increase involvement
and commitment to their treatment.
The basic idea of self-management assessments and interventions is that change
can be brought about by teaching people to use coping skills in problematic situa-
tions. self-management strategies include teaching clients how to select realistic
goals, how to translate these goals into target behaviors, how to create an action
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B E H A v I o R T H E R A P y 249
plan for change, and ways to self-monitor and evaluate their actions (Kress & Henry
2015). Generalization and maintenance of the outcomes are enhanced by encourag-
ing clients to accept the responsibility for carrying out these strategies in daily life.
In self-management programs people make decisions concerning specific behav-
iors they want to control or change. People frequently discover that a major reason
they do not attain their goals is the lack of certain skills or unrealistic expectations
of change. Hope can be a therapeutic factor that leads to change, but unrealistic
hope can pave the way for a pattern of failures in a self-change program. A self-
directed approach can provide the guidelines for change and a realistic plan that will
lead to change.
If you want to succeed in such a program, a careful analysis of the context of
the behavior pattern is essential, and you must be willing to follow some basic steps
such as these provided by Watson and Tharp (2014):
1. Selecting goals. Goals should be established one at a time, and they
should be measurable, attainable, positive, and significant for you. It is
essential that expectations be realistic.
2. Translating goals into target behaviors. Identify behaviors targeted for
change. Once targets for change are selected, anticipate obstacles and
think of ways to negotiate them.
3. Self-monitoring. Deliberately and systematically observe your own
behavior, and keep a behavioral diary in which you record your actions,
thoughts, and feelings along with comments about the relevant ante-
cedent cues and consequences. This diary can help you identify what
you need to change.
4. Working out a plan for change. A good plan involves substituting new
thoughts and behaviors for ineffective thoughts and behaviors. Devise an
action program to bring about actual changes that are in line with your
goals. Various plans for the same goal can be designed, each of which
can be effective. Some type of self-reinforcement system is necessary in
this plan because reinforcement is the cornerstone of modern behavior
therapy. Discover and select reinforcers to use until the new behaviors
have been implemented in everyday life. Practice the new behaviors you
want to acquire or refine, and take steps to ensure that the gains made
will be maintained.
5. Evaluating an action plan. Evaluate the plan for change to determine
whether goals are being achieved, and adjust and revise the plan as
other ways to meet goals are learned. Be willing to adjust your plan as
conditions change. Evaluation is an ongoing process rather than a one-
time occurrence, and self-change is a lifelong practice.
Self-management strategies have been successfully applied to many popula-
tions and problems, a few of which include coping with panic attacks, reducing
perfectionism, helping children to cope with fear of the dark, increasing creative
productivity, managing anxiety in social situations, encouraging speaking in front
of a class, increasing exercise, reducing conflict with coworkers, improving study
habits, control of smoking, and dealing with depression (Watson & Tharp, 2014).
Research on self-management has been conducted in a wide variety of health
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250 C H A P T E R N I N E
problems, a few of which include arthritis, asthma, cancer, cardiac disease, sub-
stance abuse, diabetes, headaches, vision loss, depression, nutrition, and self-health
care (Cormier et al., 2013).
Multimodal Therapy: Clinical Behavior Therapy
Multimodal therapy is a comprehensive, systematic, holistic approach to behav-
ior therapy developed by the late Arnold Lazarus (1989,1997, 2005, 2008a), a key
pioneer in clinical behavior therapy. Multimodal therapy is grounded in social cog-
nitive learning theory. The assessment process is multimodal, yet the treatment is
cognitive behavioral and draws upon empirically supported methods. It is an open
system that encourages technical eclecticism in that it applies diverse behavioral tech-
niques from a variety of theories to a wide range of problems. Whenever possible,
multimodal therapists strive to incorporate empirically supported and evidence-
based treatments in their practice (Lazarus & Lazarus, 2015). This approach serves
as a major link between some behavioral principles and the cognitive behavioral
approach that has largely replaced traditional behavioral therapy.
Multimodal therapists borrow techniques from many other therapy systems,
but Lazarus and Lazarus (2015) point out that these techniques are never used in
a shotgun manner: “a rag-tag combination of techniques without a sound ratio-
nale will likely result only in syncretistic confusion” (p. 682). Multimodal therapists
take great pains to determine precisely what relationship and what treatment strate-
gies will work best with each client and under which particular circumstances. The
underlying assumption of this approach is that because individuals are troubled
by a variety of specific problems it is appropriate that a multitude of treatment
strategies be used in bringing about change. Therapeutic flexibility and versatility,
along with breadth over depth, are highly valued, and multimodal therapists are
constantly adjusting their procedures to achieve the client’s goals. Therapists need
to decide when and how to be challenging or supportive and how to adapt their rela-
tionship style to the needs of the client. The therapeutic relationship is the soil that
enables techniques to take root, and multimodal therapists recognize that a good
working alliance is a cornerstone in the foundation of effective therapeutic prac-
tice (Lazarus & Lazarus, 2015). Multimodal therapists tend to be very active during
therapist sessions, functioning as trainers, educators, consultants, coaches, and role
models. They provide information, instruction, and feedback as well as modeling
assertive behaviors. They offer suggestions, positive reinforcements, and are appro-
priately self-disclosing.
For an illustration of how Dr. Lazarus applies the BASIC I.D. assessment model
to the case of Ruth, along with examples of various techniques he uses, see Case
Approach to Counseling and Psychotherapy (Corey, 2013, chap. 7).
Mindfulness and Acceptance-Based Approaches
The third generation (or “third wave”) of behavior therapy emphasizes con-
siderations that were considered off limits for behavior therapists until recently,
including mindfulness, acceptance, the therapeutic relationship, spirituality, val-
ues, meditation, being in the present moment, and emotional expression (Hayes,
Follette, & Linehan, 2004; Herbert & Forman, 2011). Third-generation behavior
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B E H A v I o R T H E R A P y 251
therapies center around five interrelated core themes: (1) an expanded view of psy-
chological health, (2) a broad view of acceptable outcomes in therapy, (3) accep-
tance, (4) mindfulness, and (5) creating a life worth living (Speigler, 2016).
Mindfulness is “the awareness that emerges through having attention on pur-
pose, in the present moment, and nonjudgmentally, to the unfolding of experience
moment by moment” (Kabat-Zinn, 2003, p. 145). In mindfulness practice, clients
train themselves to intentionally focus on their “present experience with accep-
tance” (Siegel, 2010, p. 27) and develop an attitude of curiosity and compassion
toward present experience.
Mindfulness shows promise across a broad range of clinical problems, includ-
ing the treatment of depression, anxiety disorders, relationship problems, substance
abuse, and psychophysiological disorders (Germer, Siegel, & Fulton, 2013). It is
useful in treating posttraumatic stress disorder among military veterans. Through
mindfulness exercises, veterans may be better able to observe repetitive negative
thinking and prevent extensive engagement with maladaptive ruminative pro-
cesses (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Many therapeutic
approaches are incorporating mindfulness and meditation, as well as other contem-
plative practices, in the counseling process, and this trend seems likely to continue
(Worthington, 2011).
acceptance is a process involving receiving one’s present experience without
judgment or preference, but with curiosity and kindness, and striving for full aware-
ness of the present moment (Germer, 2013). Acceptance is an alternative way of
responding to our internal experience. By replacing judgment, criticism, and avoid-
ance with acceptance, the likely result is increased adaptive functioning (Antony &
Roemer, 2011b). Mindfulness and acceptance approaches are also good avenues for
the integration of spirituality in the counseling process.
For an extensive discussion of mindfulness and acceptance, see Acceptance and
Mindfulness in Cognitive Behavior Therapy: Understanding and Applying the New Therapies
(Herbert & Forman, 2011).
Recent developments in the cognitive behavioral tradition include four major
approaches: (1) dialectical behavior therapy, which has become a recognized treatment
for borderline personality disorder (Linehan, 1993a, 1993b, 2015); (2) mindfulness-
based stress reduction, an 8- to 10-week group program that applies mindfulness
techniques to coping with stress and promoting physical and psychological health
(Kabat-Zinn, 1990, 2003); (3) mindfulness-based cognitive therapy, aimed primarily at
treating depression (Segal, Williams, & Teasdale, 2013); and (4) acceptance and commit-
ment therapy, which encourages clients to accept unpleasant sensations rather than
attempting to control or change them (Hayes, Strosahl, & Houts, 2005; Hayes, Stro-
sahl, & Wilson, 2011). All four of these approaches use mindfulness strategies that
have been subjected to empirical scrutiny, a hallmark of the behavioral tradition.
Dialectical Behavior Therapy (DBT) Dialectical behavior therapy was originally
developed to treat chronically suicidal individuals diagnosed with borderline
personality disorder (BPD), and it is now recognized as a major psychological
treatment for this population. Formulated by Linehan (1993a, 1993b, 2015), who
was motivated to alleviate emotional suffering for those miserable enough to
consider suicide, DBT has been proven effective in treating a wide range of disorders,
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252 C H A P T E R N I N E
including substance dependence, depression, posttraumatic stress disorder (PTSD),
eating disorders, suicidal behavior, and nonsuicidal self-injury (Linehan, 2015).
DBT is a promising blend of behavioral and psychoanalytic techniques for treat-
ing borderline personality disorders. Like analytic therapy, DBT emphasizes the
importance of the psychotherapeutic relationship, validation of the client, the etio-
logic importance of the client having experienced an “invalidating environment” as
a child, and confrontation of resistance. DBT treatment includes both acceptance-
and change-oriented strategies. Mindfulness procedures are taught to develop an
attitude of acceptance (Fishman, Rego, & Muller, 2011; Kuo & Fitzpatrick, 2015).
The treatment program is geared toward helping clients make changes in their
behavior and environment while communicating acceptance of their current state
(Kuo & Fitzpatrick, 2015; Robins & Rosenthal, 2011). To help clients who have par-
ticular problems with emotional regulation, DBT teaches clients to recognize and
accept the existence of simultaneous, opposing forces. By acknowledging this fun-
damental dialectic relationship—such as not wanting to engage in a certain behav-
ior, yet knowing they have to engage in the behavior if they want to achieve a desired
goal—clients can learn to integrate the opposing notions of acceptance and change,
and the therapist can teach clients how to regulate their emotions and behaviors.
DBT skills training is not a “quick fix” approach. It generally involves a mini-
mum of one year of treatment and includes both individual therapy and skills train-
ing done in a group. DBT is an empirically supported intervention that employs
behavioral and cognitive behavioral techniques, including a form of exposure ther-
apy in which the client learns to tolerate painful emotions without enacting self-
destructive behaviors. DBT draws upon Zen teachings and practices to integrate
mindfulness and acceptance-based techniques in therapy (Kuo & Fitzpatrick, 2015).
Some of the Zen Buddhist principles and practices include being aware of the pres-
ent moment, seeing reality without distortion, accepting reality without judgment,
letting go of attachments that result in suffering, developing a greater degree of
acceptance of self and others, and entering fully into present activities without sepa-
rating oneself from ongoing events and interactions (Robins & Rosenthal, 2011).
DBT promotes a structured, predictable therapeutic environment. The goals are
tailored to each individual. Therapists assist clients in using whatever skills they
possess or are learning to navigate crises more effectively and to address problem
behaviors (Robins & Rosenthal, 2011). Skills are taught in four modules: mindful-
ness, interpersonal effectiveness, emotional regulation, and distress tolerance (Kuo
& Fitzpatrick, 2015).
Mindfulness is a fundamental skill in DBT that teaches individuals to be aware
of and accept the world as it is and to respond to each moment effectively. Through
mindfulness, clients learn to embrace and tolerate the intense emotions they experi-
ence when facing distressing situations. Interpersonal effectiveness teaches clients to ask
for what they need and how to say “no” while maintaining self-respect and relation-
ships with others. This skill entails increasing the chances that a client’s goals will
be met, while at the same time not damaging the relationship. Emotional regulation
includes identifying emotions, identifying obstacles to changing emotions, reduc-
ing vulnerability, and increasing positive emotions. Clients learn the benefits of
regulating emotions such as anger, depression, and anxiety. Distress tolerance is aimed
at helping individuals to calmly recognizing emotions associated with negative
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B E H A v I o R T H E R A P y 253
situations without becoming overwhelmed by these situations. Clients learn how to
tolerate pain or discomfort skillfully.
DBT helps individuals acquire, strengthen, and generalize the skills they learn in
therapy to their daily environments (Kuo & Fitzpatrick, 2015). Because DBT places
heavy emphasis on didactic instruction and teaching mindfulness skills, therapists
must obtain training to become competent in applying these skills and be able to
model specific strategies and attitudes for clients. Therapists who want to employ
mindfulness strategies must also have personal understanding of these interven-
tions to be able to effectively use them with clients.
For a more detailed review of DBT, see DBT Skills Training Manual (Linehan,
2015), which includes instructions for orienting clients to DBT and explains how
to use many skills in DBT. Another useful resource for a more detailed discussion of
DBT is Robins and Rosenthal (2011).
Mindfulness-Based Stress Reduction (MBSR) Jon Kabat-Zinn, at the University
of Massachusetts, developed MBSR in 1979 to see if it was possible to create a
training program to relieve medical patients of stress, pain, illness, and other forms
of suffering. The eight-week structured group program involves training people
in mindfulness meditation, and today instructors are often not mental health
clinicians. Originally designed to help people increase their responsibility for their
own well-being and to actively develop inner resources for treating their physical
health concerns (Kabat-Zinn, 2003), MBSR is not a form of psychotherapy per se,
but it can be an adjunct to therapy.
The essence of mindfulness-based stress reduction (MBSR) consists of the
notion that much of our distress and suffering results from continually wanting
things to be different from how they actually are (Salmon, Sephton, & Dreeben,
2011). MBSR assists people in learning how to live more fully in the present rather
than ruminating about the past or being overly concerned about the future. MBSR
does not actively teach cognitive modification techniques, nor does it label certain
cognitions as “dysfunctional,” because this is not consistent with the nonjudgmen-
tal attitude one strives to cultivate in mindfulness practice.
The approach adopted in the MBSR program is to develop the capacity for sus-
tained directed attention through formal and informal meditation practice. There
is a heavy emphasis on experiential learning and the process of client self-discovery
(Dimidjian & Linehan, 2008). In formal practice, skills taught include sitting medi-
tation and mindful yoga, which are aimed at cultivating mindfulness. The program
includes a body scan meditation, which helps clients to observe all the sensations in
their body. Clients are encouraged to bring mindfulness into all of their daily activi-
ties, and this informal practice includes being mindful when standing, walking, eat-
ing, and doing chores. Those who are involved in the program are encouraged to
practice formal mindfulness meditation for 45 minutes daily.
The MBSR program is designed to teach participants to relate to external and
internal sources of stress in constructive ways, and an ongoing commitment to culti-
vate and practice its principles in each moment is required. Acquiring a mindful way of
being is not a simple behavioral technique but is more like an art form that individu-
als develop over time as they deepen their focus through disciplined practice. Kabat-
Zinn (2003) makes it clear that mindfulness is not about getting anywhere or fixing
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254 C H A P T E R N I N E
anything: “It is an invitation to allow oneself to be where one already is and to know
the inner and outer landscape of the direct experience in each moment” (p. 148).
MBSR programs are offered in hospitals, clinics, schools, workplaces, corporate
offices, law schools, prisons, and inner-city health centers (Kabat-Zinn, 2003). MBSR
has many clinical applications, and it is expected that the approach will evolve to
address a range of negative psychological states, such as anxiety, stress, and depres-
sion. This approach has many applications in the area of health and wellness and in
promoting healthy lifestyle changes. Numerous research reviews and meta-analyses
indicate that mindfulness, acceptance, and compassion-based treatments are effec-
tive in promoting physical and psychological health (Germer, 2013). One of these
studies suggests that MBSR training may lead to changes in the brain that result in
people being able to better cope with negative emotional reactions under stress (as
cited in Kabat-Zinn, 2003).
Kabat-Zinn’s (1990, 1994) books offer a comprehensive treatment of MBSR, and
they did a great deal to popularize the program he developed. An excellent resource
for a more detailed treatment of MBSR is Salmon, Sephton, and Dreeben (2011).
Mindfulness-Based Cognitive Therapy (MBCT) This program is a comprehensive
integration of the principles and skills of mindfulness applied to the treatment of
depression (Segal et al., 2013). MBCT is an eight-week group treatment program of
two-hour weekly sessions adapted from Kabat-Zinn’s (1990, 2003) mindfulness-based
stress reduction program. The program integrates techniques from MBSR with teaching
cognitive behavioral skills to clients. The primary aim is to change clients’ awareness of
and relation to their negative thoughts. Participants are taught how to respond in skillful
and intentional ways to their automatic negative thought patterns (Hammond, 2015).
Segal, Williams, and Teasdale (2013) describe kindness and self-compassion as
essential components of MBCT. Mindfulness is a way of developing self-compassion,
which is a form of self-care when facing difficult situations. Mindfulness practices
focus on moment-to-moment experiencing and assist clients in developing an atti-
tude of open awareness and acceptance of what is rather than being self-critical. When
we acknowledge our shortcomings without critical judgment, we can begin to treat
ourselves with kindness. We can intentionally activate goodwill toward ourselves and
others while experiencing emotions such as anger, anxiety, and depression. Research
has shown that self-compassion is positively associated with emotional well-being and
decreased levels of anxiety and depression (Morgan, Morgan, & Germer, 2013; Neff,
2012). Other research findings on the association between self-compassion and emo-
tional well-being have been reported by Neff (2012):
�� Self-compassionate people recognize when they are suffering, yet they
are kind toward themselves in these moments.
�� Self-compassion is associated with greater wisdom and emotional
intelligence.
�� Self-compassion is associated with feelings of life satisfaction and con-
nection to others.
�� Self-compassionate individuals tend to experience increased happiness,
optimism, curiosity, and positive emotions.
�� Self-compassion engenders compassion toward others.
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B E H A v I o R T H E R A P y 255
Morgan, Morgan, and Germer (2013) report that there is ample evidence that
mindfulness meditation enhances the ability to pay attention in a concentrated and
sustained manner. Being able to attend to present experiencing is a route to devel-
oping compassion toward oneself and expressing compassion toward others. Mind-
fulness is something that is caught more than something that is taught. The attitude
and behavior of the instructor/facilitator of the MBCT group are critical in helping
participants acquire an accepting way of being and discarding self-critical and judg-
mental habits.
Segal, Williams, and Teasdale (2013) describe the essence of eight sessions in the
MBCT program:
�� Therapy begins by identifying negative automatic thinking of people
experiencing depression and by introducing some basic mindfulness
practices.
�� In the second session, participants learn about the reactions they have
to life experiences and learn more about mindfulness practices. Clients
learn the importance of kindness and self-compassion, both to self and
to others.
�� The third session is focused on gathering the scattered mind; partici-
pants learn breathing techniques and focus their attention on their
present experiencing. Clients learn how to anchor thoughts with a
focus on the breath while allowing experience to unfold.
�� In session four, the emphasis is on learning to experience the moment
without becoming attached to outcomes; participants practice sitting
meditation and mindful walking.
�� The fifth session teaches participants how to accept their experiencing
without holding on; participants learn the value of allowing and letting be.
�� Session six is used to describe thoughts as “merely thoughts”; clients
learn that they do not have to act on their thoughts. They can tell them-
selves, “I am not my thoughts” and “Thoughts are not facts.”
�� In session seven, participants learn how to take care of themselves and
to develop an action plan to deal with the threat of relapse.
�� Session eight focuses on maintaining and extending new learning; clients
learn how to generalize their mindfulness practices to daily life.
MBCT emphasizes experiential learning, in-session practice, learning from feed-
back, completing homework assignments, and applying what is learned in the pro-
gram to challenging situations encountered outside of the sessions. The brevity of
MBCT makes this approach an efficient and cost-effective treatment. For a more
detailed review of MBCT, see Mindfulness-Based Cognitive Therapy for Depression (Segal
et al., 2013).
Acceptance and Commitment Therapy (ACT) Another mindfulness-based
approach is acceptance and commitment therapy (Hayes et al., 2005, 2011). ACT is a
unique empirically based psychological intervention that uses acceptance and
mindfulness strategies, together with commitment and behavior change strategies,
to increase psychological flexibility. ACT involves fully accepting present experience
and mindfully letting go of obstacles. In this approach “acceptance is not merely
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256 C H A P T E R N I N E
tolerance—rather it is the active nonjudgmental embracing of experience in the
here and now” (Hayes, 2004, p. 32). Acceptance is a stance or posture from which
to conduct therapy and from which a client can conduct life that provides an
alternative to contemporary forms of cognitive behavioral therapy. In contrast to the
cognitive behavioral approaches discussed in Chapter 10, in which dysfunctional
thoughts are identified and challenged, in ACT there is little emphasis on changing
the content of a client’s thoughts. Hayes has found that confronting maladaptive
cognitions strengthens rather than reduces these cognitions. Instead, the emphasis
is on acceptance (nonjudgmental awareness) of cognitions. The goal is for individuals
to become aware of and examine their thoughts. Clients learn how to change their
relationship to their thoughts. They learn how to accept yet not identify with
thoughts and feelings they may have been trying to deny.
Values are a basic part of the therapeutic process, and the work of ACT depends
on what an individual wants and values. Client and therapist work together to identify
personal values in areas such as work, relationships, spirituality, and well-being (Bat-
ten & Cairrochi, 2015). ACT practitioners might ask clients, “What do you want your
life to stand for?” Therapy involves assisting clients to choose values they want to live
by, designing specific goals, and taking steps to achieve their goals (Speigler, 2016).
A commitment to action is essential, and clients are asked to make mindful
decisions about what they are willing to do to live a valued and meaningful life. Con-
crete homework and behavioral exercises as two ways clients can commit to action.
For example, one form of homework asks clients to write down life goals or things
they value in various aspects of their lives. Clients learn to allow experience to come
and go while they pursue a meaningful life.
ACT is an effective form of therapy that continues to influence the practice
of behavior therapy. Germer (2013) suggests “mindfulness appears to be drawing
clinical theory, research, and practice closer together, and helping to integrate the
private and professional lives of therapists” (p. 13). ACT emphasizes common pro-
cesses across clinical disorders, which makes it easier to learn basic treatment skills.
Practitioners can then implement basic principles in diverse and creative ways. ACT
has been empirically shown to be effective in the treatment of a variety of disorders,
including substance abuse, depression, anxiety, phobias, posttraumatic stress disor-
der, and chronic pain (Batten & Cairrochi, 2015).
For an in-depth discussion of the role of mindfulness in psychotherapeutic
practice, four highly recommended books are Acceptance and Mindfulness in Cognitive
Behavior Therapy: Understanding and Applying the New Therapies (Herbert & Forman,
2011), Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Hayes et
al., 2004), Mindfulness and Psychotherapy (Germer et al., 2013), and Wisdom and Compas-
sion in Psychotherapy: Deepening Mindfulness in Clinical Practice, (Germer & Siegel, 2012).
Application to Group Counseling
Behavioral group therapy incorporates classical behavior therapy treatment
principles rooted in classical conditioning, operant conditioning, and social learn-
ing theory. The focus of a behavioral group is on teaching, modeling, and applying
scientific principles to target specific behaviors for change (Kress & Henry, 2015).
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B E H A v I o R T H E R A P y 257
Group-based behavioral approaches emphasize teaching clients self-management
skills and a range of new coping behaviors, as well as how to restructure their
thoughts. Clients can learn to use these techniques to control their lives, deal effec-
tively with present and future problems, and function well after they complete their
group experience. Many groups are designed primarily to increase the client’s degree
of control and freedom in specific aspects of daily life.
Group leaders who function within a behavioral framework may develop tech-
niques from various theoretical viewpoints. Behavioral practitioners make use of a
brief, active, directive, structured, collaborative, psychoeducational model of therapy
that relies on empirical validation of its concepts and techniques. The leader follows
the progress of group members through the ongoing collection of data before, dur-
ing, and after all interventions. Such an approach provides both the group leader and
the members with continuous feedback about therapeutic progress. Today, many
groups in community agencies demand this kind of accountability.
Behavioral group therapy has some unique characteristics that set it apart
from most of the other group approaches. A distinguishing characteristic of
behavioral practitioners is their systematic adherence to specification and mea-
surement. The specific unique characteristics of behavioral group therapy include
(1) conducting a behavioral assessment, (2) precisely spelling out collaborative
treatment goals, (3) formulating a specific treatment procedure appropriate to
a particular problem, and (4) objectively evaluating the outcomes of therapy.
Behavior therapists tend to utilize short-term, time-limited interventions aimed
at efficiently and effectively solving problems and assisting members in develop-
ing new skills.
Behavioral group leaders assume the role of teacher and encourage members to
learn and practice skills in the group that they can apply to everyday living. Group
leaders typically assume an active, directive, and supportive role in the group and
apply their knowledge of behavioral principles and skills to the resolution of prob-
lems. They model active participation and collaboration by their involvement with
members in creating an agenda, designing homework, and teaching skills and new
behaviors. Leaders carefully observe and assess behavior to determine the conditions
that are related to certain problems and the conditions that will facilitate change.
Members in behavioral groups identify specific skills that they lack or would like to
enhance. Assertiveness and social skills training fit well into a group format. Relax-
ation procedures, behavioral rehearsal, modeling, coaching, meditation, and mind-
fulness techniques are often incorporated in behavioral groups. The experience of
being mindful is expanded in the group setting where people meditate and are still
in the presence of others. Most of the other techniques described earlier in this chap-
ter can be applied to group work.
Today, most behavior therapy groups blend cognitive and behavioral concepts
and techniques, with few having a strictly behavioral focus (Kress & Henry, 2015).
There are many different types of groups with a behavioral twist, or groups that
blend both behavioral and cognitive methods for specific populations. Structured
groups, with a psychoeducational focus, are especially popular in various settings
today. At least four general approaches can be applied to the practice of behavioral
groups: (1) social skills training groups, (2) psychoeducational groups with specific
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258 C H A P T E R N I N E
themes, (3) stress management groups, and (4) mindfulness and acceptance-based
behavior therapy in groups.
For a more detailed discussion of cognitive behavioral approaches to groups, see
Corey (2016, chap. 13).
Behavior Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
Behavior therapy has some clear advantages over many other theories in
counseling culturally diverse clients. Because of their cultural and ethnic back-
grounds, some clients hold values that are contrary to the free expression of feelings
and the sharing of personal concerns. Behavioral counseling does not generally place
emphasis on experiencing catharsis. Rather, it stresses changing specific behaviors
and developing problem-solving skills. Some potential strengths of the behavioral
approaches in working with diverse client populations include its specificity, task
orientation, focus on objectivity, focus on cognition and behavior, action orienta-
tion, dealing with the present more than the past, emphasis on brief interventions,
teaching coping strategies, and problem-solving orientation. The attention given to
transfer of learning and the principles and strategies for maintaining new behavior
in daily life are crucial. Clients who are looking for action plans and specific behav-
ioral change are likely to cooperate with this approach because they can see that it
offers them concrete methods for dealing with their problems of living.
Behavior therapy focuses on environmental conditions that contribute to a cli-
ent’s problems. Social and political influences can play a significant role in the lives
of people of color through discriminatory practices and economic problems, and
the behavioral approach takes into consideration the social and cultural dimensions
of the client’s life. Behavior therapy is based on an experimental analysis of behavior
in the client’s own social environment and gives special attention to a number of
specific conditions: the client’s cultural conception of problem behaviors, establish-
ing specific therapeutic goals, arranging conditions to increase the client’s expecta-
tion of successful therapeutic outcomes, and employing appropriate social influence
agents (Tanaka-Matsumi, Higginbotham, & Chang, 2002). The foundation of ethi-
cal practice involves a therapist’s familiarity with the client’s culture, as well as the
competent application of this knowledge in formulating assessment, diagnostic,
and treatment strategies.
The behavioral approach has moved beyond treating clients for a specific symp-
tom or behavioral problem. Instead, it stresses a thorough assessment of the person’s
life circumstances to ascertain not only what conditions give rise to the client’s prob-
lems but also whether the target behavior is amenable to change and whether such a
change is likely to lead to a significant improvement in the client’s total life situation.
In designing a change program for clients from diverse backgrounds, effective
behavioral practitioners conduct a functional analysis of the problem situation. This
assessment includes the cultural context in which the problem behavior occurs, the con-
sequences both to the client and to the client’s sociocultural environment, the resources
within the environment that can promote change, and the impact that change is likely
to have on others in the client’s social surroundings. Assessment methods should be
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B E H A v I o R T H E R A P y 259
chosen with the client’s cultural background in mind (Spiegler, 2016; Tanaka-Matsumi
et al., 2002). Counselors must be knowledgeable as well as open and sensitive to issues
such as these: What is considered normal and abnormal behavior in the client’s culture?
What are the client’s culturally based conceptions of his or her problems? What is the
potential role of spirituality or religion in the client’s life? What kind of information
about the client is essential in making an accurate assessment?
Shortcomings From a Diversity Perspective
Although behavior therapy is sensitive to differences among clients in a broad sense,
behavior therapists need to become more responsive to specific issues pertaining to
all forms of diversity. Because race, gender, ethnicity, and sexual orientation are crit-
ical variables that influence the process and outcome of therapy, it is essential that
behavior therapists pay careful attention to these factors and address social justice
issues as they arise in a client’s therapy.
Some behavioral counselors may focus on using a variety of techniques in narrowly
treating specific behavioral problems. Instead of viewing clients in the context of their
sociocultural environment, these practitioners concentrate too much on problems
within the individual. In doing so they may overlook significant issues in the lives of cli-
ents. Such practitioners are not likely to bring about beneficial changes for their clients.
The fact that behavioral interventions often work well raises an interesting issue
in multicultural counseling. When clients make significant personal changes, it is
very likely that others in their environment will react to them differently. Before
deciding too quickly on goals for therapy, the counselor and client need to discuss
the complexity inherent in change. It is essential for therapists to conduct a thor-
ough assessment of the interpersonal and cultural dimensions of the problem. Cli-
ents should be helped in assessing the possible consequences of some of their newly
acquired social skills. Once goals are determined and therapy is under way, clients
should have opportunities to talk about the problems they encounter as they bring
new skills and behaviors into their home and work settings.
I n Stan’s case many specific and interrelated prob-lems can be identified through an assessment pro-
cess. Behaviorally, he is defensive, avoids eye contact,
speaks hesitantly, uses alcohol excessively, has a poor
sleep pattern, and displays various avoidance behaviors
in social and interpersonal situations. In the emotional
area, Stan has a number of specific problems, some of
which include anxiety, panic attacks, depression, fear
of criticism and rejection, feeling worthless and stu-
pid, and feeling isolated and alienated. He experiences
a range of physiological complaints such as dizziness,
heart palpitations, and headaches. Cognitively, he wor-
ries about death and dying, has many self-defeating
thoughts and beliefs, is governed by categorical imper-
atives (“shoulds,” “oughts,” “musts”), engages in fatal-
istic thinking, and compares himself negatively with
others. In the interpersonal area, Stan is unassertive, has
an unsatisfactory relationship with his parents, has
few friends, is afraid of contact with women and fears
intimacy, and feels socially inferior.
After completing this assessment, I focus on help-
ing Stan define the specific areas where he would like
to make changes. Before developing a treatment plan,
I assist Stan in understanding the purposes of his
behavior. I then educate Stan about how the therapy
sessions (and his work outside of the sessions) can
Behavior Therapy Applied to the Case of Stan
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help him reach his goals. Early during treatment I help
Stan translate some of his general goals into concrete
and measurable ones. When Stan says, “I want to feel
better about myself,” I help him define more specific
goals. When he says, “I want to get rid of my inferior-
ity complex,” I reply: “What exactly do you mean by
this? What are some situations in which you feel infe-
rior? What do you actually do that leads to feelings of
inferiority?” Stan’s concrete aims include his desire
to function without drugs or alcohol. I suggest that
he keep a record of when he drinks and what events
lead to drinking. My hope is that Stan will establish
goals that are based on positive markers, not negative
goals. Instead of focusing on what Stan would like to
get rid of, I am more interested in what he would like
to acquire and develop.
Stan indicates that he does not want to feel apolo-
getic for his existence. I introduce behavioral skills
training because he has trouble talking with his boss
and coworkers. I demonstrate specific skills that he
can use in approaching them more directly and confi-
dently. This procedure includes modeling, role playing,
and behavior rehearsal. He then tries more effective
behaviors with me as I play the role of the boss. I give
him feedback on how strong or apologetic he seemed.
Imaginal exposure and systematic desensitization
are appropriate in working with Stan’s fear of failing.
Before using these procedures, I explain the procedure
to Stan and get his informed consent. Stan first learns
relaxation procedures during the sessions and then
practices them daily at home. Next, he lists his specific
fears relating to failure, and he then generates a hierar-
chy of fear items. Stan identifies his greatest fear as fear
of dating and interacting with women. The least fear-
ful situation he identifies is being with a female stu-
dent for whom he does not feel an attraction. I first do
some systematic desensitization on Stan’s hierarchy.
Stan begins repeated, systematic exposure to items
that he finds frightening, beginning at the bottom of
the fear hierarchy. He continues with repeated expo-
sure to the next fear hierarchy item when exposure to
the previous item generates only mild fear. Part of the
process involves exposure exercises for practice in vari-
ous situations away from the therapy office.
The goal of therapy is to help Stan modify the
behavior that results in his feelings of guilt and anxi-
ety. By learning more appropriate coping behaviors,
eliminating unrealistic anxiety and guilt, and acquiring
more adaptive responses, Stan’s presenting symptoms
decrease, and he reports a greater degree of satisfaction.
Questions for Reflection
�� How would you collaboratively work with Stan in
identifying specific behavioral goals to give a direc-
tion to your therapy?
�� What behavioral techniques might be most appro-
priate in helping Stan with his problems?
�� Stan indicates that he does not want to feel apolo-
getic for his existence. How might you help him
translate this wish into a specific behavioral goal?
What behavioral techniques might you draw on in
helping him in this area?
�� What homework assignments are you likely to
suggest for Stan?
I n daily life, Gwen has a tendency to try to get every-thing done without enlisting the support of others.
In our previous session, she decided on a goal of ask-
ing for support from others both at home and at work.
We engaged in behavioral rehearsals in which Gwen
practiced asking someone for support. Gwen found
this difficult, but she hesitantly said she was willing
to try out these new behaviors. Her homework was to
Behavior Therapy Applied to the Case of Gwen*
visit CengageBrain.com or watch the DvD
for the video program Theory and Practice of
Counseling and Psychotherapy: The Case of Stan and
Lecturettes, Session 7 (behavior therapy), for a
demonstration of my approach to counseling
Stan from this perspective. This session involves
collaboratively working on homework and
behavior rehearsals to experiment with assertive
behavior.
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a behavior therapy perspective and applying this model to Gwen.
260 C H A P T E R N I N E
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ask for help both at work and at home. Gwen is late
for our session, and when she arrives she looks tired
and defeated.
Gwen: Sorry I am late. I left work early to take my
mother to the doctor, and the appointment ran
longer than I expected.
Therapist: I am pleased you were able to make it,
but our session will be shorter. Last week you
talked about feeling disconnected from your
husband. We agreed that asking him for assis-
tance and sharing your daily life with him might
help you communicate with each other. What
have you done this week to get support and share
more at home?
Gwen: I expressed to colleagues that I needed help
when completing some tasks at work, but I fell
back into the same pattern of silence when at home
with Ron.
Therapist: Tell me more about falling back into the
same pattern of silence.
Gwen: I wanted to ask Ron to help with my mom,
but ultimately I feel like she is my mom and my
responsibility. He sees what I am doing and could
offer to pitch in.
Therapist: You seemed eager to express your need for
support to Ron, but then something stopped you.
What do you think caused you to stop? [Using the
A-B-C model]
Gwen: I hate to ask. It is my responsibility. I think I
am the only one who can do it. I would feel like I
was putting a burden on Ron’s shoulders if I asked
for help.
Therapist: You must feel an overwhelming amount of
pressure being solely responsible for so much.
Gwen: Yes, it is hard to make sense of it all.
Therapist: Let me see if I understand. It sounds
as though taking care of your mom is your sole
responsibility and not Ron’s [antecedent]. You
do not want to feel like a burden to Ron, so
you stop yourself from asking for support
[behavior].
Gwen: Yes, when I get home I want to talk, but I do
not want to become a burden on someone I love.
So I just withdraw into myself [consequence].
Assessment is a large part of behavioral therapy, and
reviewing homework assignments helps us to see if our
approach is effective. Although Gwen was aware of her
pattern of silence at home, she was not able to modify
her behavior and express her feelings to her husband.
I decide to introduce Gwen to the concept of
mindfulness to help her stop the automatic behaviors
that have kept her feeling stressed and overwhelmed.
Gwen has difficulty being in the present moment, and
she could profit from slowing down and engaging
in self-care activities. Mindfulness practice can bring
increased peace and calm into her life and quiet the
constant chatter in her mind. I want to give Gwen
some simple tools she can use and practice at home.
Therapist: Gwen, take a moment to sit quietly. Let
your thoughts flow away and concentrate your
attention on the present moment. How are you
feeling? [She begins to notice bodily sensations] Gwen
please bring your awareness to the top of your head
and slowly begin to scan your entire body for any
sensations of tension or tightness. What are you
noticing?
Gwen: I am aware of tightness in my chest. It feels like
a ball of stress.
Therapist: Focus all of your attention on the sensa-
tion in your chest. As you consciously tell yourself
to relax, simply notice the sensations without judg-
ing them. How are you feeling?
Gwen: It’s a little strange, but I feel more at ease than
when I first walked in the door.
Therapist: Do you think you can practice this mind-
fulness at home this week and focus on what you
want to bring into your life?
Gwen: I do want to communicate better with my
husband and be able to ask him for support. I feel
much more relaxed here now, and I would like to
try to feel that at home too. Calming myself and
staying in the moment is a new experience for me.
Therapist: You have a good start on learning how
mindfulness feels; let’s see how much progress you
can make at home as you practice this week.
Gwen: OK, I feel less stressed when I slow down and
try to relax in the moment. I am going to practice
this every day during the week. [Goal-setting is an
important part of behavior therapy]
B E H A v I o R T H E R A P y 261
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Summary and Evaluation
Summary
Behavior therapy is diverse with respect not only to basic concepts but also
to techniques that can be applied in coping with specific problems with a wide range
of clients. The behavioral movement includes four major areas of development:
classical conditioning, operant conditioning, social-cognitive theory, and increas-
ing attention to the cognitive factors influencing behavior (see Chapter 10). Third-
generation behavior therapies are recent developments in the field, and they include
mindfulness and acceptance-based behavior therapies. A unique characteristic of
all forms of behavior therapy is its strict reliance on the principles of the scientific
method. Concepts and procedures are stated explicitly, tested empirically, and
revised continually. Treatment and assessment are interrelated and occur simulta-
neously. Research is considered to be a basic aspect of the approach, and therapeutic
techniques are continually refined.
A cornerstone of behavior therapy is identifying specific goals at the outset of
the therapeutic process. In helping clients achieve their goals, behavior therapists
typically assume an active and directive role. Although the client generally deter-
mines what behavior will be changed, the therapist typically determines how this
behavior can best be modified. In designing a treatment plan, behavior therapists
employ techniques and procedures from a wide variety of therapeutic systems and
apply them to the unique needs of each client.
Contemporary behavior therapy places emphasis on the interplay between the
individual and the environment. Behavioral strategies can be used to attain both
individual goals and societal goals. Because cognitive factors have a place in the
practice of behavior therapy, techniques from this approach can be used to attain
humanistic ends. It is clear that bridges can connect humanistic and behavioral
therapies, especially with the current focus of attention on self-management and
the incorporation of mindfulness and acceptance-based approaches into behav-
ioral practice. Mindfulness practices rely on experiential learning and client dis-
covery rather than on didactic instruction. Mindfulness is a way of being that takes
ongoing effort to develop and refine (Kabat-Zinn, 2003). Self-compassion is a foun-
dational part of the new wave of behavior therapies and is linked to an increased
I encourage Gwen to practice paying attention to
her behaviors and to consider using mindfulness
practice as a way of refocusing on what she wants
to bring into her life. It is my hope that her mind-
fulness practice will lead to an overall reduction in
stress and increased presence and connection in her
life.
Questions for Reflection
�� What could be the consequence(s) if Gwen does
not change her behavior?
�� What kind of homework might you suggest to
Gwen?
�� What kind of mindfulness practices would you
like to incorporate into your daily life?
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B E H A v I o R T H E R A P y 263
sense of well-being. These newer approaches represent a blend of Eastern practices
and Western methodology. Contemporary behavior therapy has broadened from
a narrow focus on dealing with simple problems to addressing complex aspects of
personal functioning.
Contributions of Behavior Therapy
Behavior therapy challenges us to reconsider our global approach to counseling. Some
may assume they know what a client means by the statement, “I feel unloved; life
has no meaning.” A humanist might nod in acceptance to such a statement, but the
behaviorist may respond with: “Who specifically do you feel is not loving you?” “What
is going on in your life to make you think it has no meaning?” “What are some specific
things you might be doing that contribute to the state you are in?” “What would you
most like to change?” A key strength of behavior therapy is its precision in specifying
goals, target behaviors, and procedures. The specificity of the behavioral approaches
helps clients translate unclear goals into concrete plans of action, and it helps both
the counselor and the client to keep these plans clearly in focus. Ledley, Marx, and
Heimberg (2010) state that therapists can help clients learn about the contingencies
that maintain their problematic thoughts and behaviors and then teach them ways
to make the changes they want. Techniques such as role playing, relaxation proce-
dures, behavioral rehearsal, coaching, guided practice, modeling, feedback, learning
by successive approximations, mindfulness skills, and homework assignments can be
included in any therapist’s repertoire, regardless of theoretical orientation.
An advantage behavior therapists have is the wide variety of specific behavioral
techniques at their disposal. Because behavior therapy stresses doing, as opposed
to merely talking about problems and gathering insights, practitioners use many
behavioral strategies to assist clients in formulating a plan of action for changing
behavior. The basic therapeutic conditions stressed by person-centered therapists—
active listening, accurate empathy, positive regard, genuineness, respect, acceptance,
and immediacy—need to be integrated in a behavioral framework.
A major contribution of behavior therapy is its emphasis on research into and
assessment of treatment outcomes. It is up to practitioners to demonstrate that
therapy is working. If progress is not being made, therapists look carefully at the
original analysis and treatment plan. Of all the therapies presented in this book, this
approach and its techniques have been subjected to the most empirical research.
Behavioral practitioners are put to the test of identifying specific interventions that
have been demonstrated to be effective.
Evidence-based therapies (EBT) are a hallmark of both behavior therapy and
cognitive behavior therapy. To their credit, behavior therapists are willing to exam-
ine the effectiveness of their procedures in terms of the generalizability, meaningful-
ness, and durability of change. Most studies show that behavior therapy methods
are more effective than no treatment. Moreover, a number of behavioral and cogni-
tive behavioral procedures are currently the best treatment strategies available for
depression, obsessive-compulsive disorder, panic disorder, social phobia, hypochon-
driasis, generalized anxiety disorder, posttraumatic stress disorder, eating disorders,
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264 C H A P T E R N I N E
borderline personality disorder, bipolar disorder, and childhood disorders (Hollon
& DiGiuseppe, 2011).
The new generation of mindfulness and acceptance-based therapies has shifted
behavior therapy from treating simple and discrete problems to a more complex and
complete psychotherapy that is based in behavioral principles (Prochaska & Nor-
cross, 2014). Prochaska and Norcross confidently predict an increase and expansion
of the third-wave therapies in the next decade and state that these approaches will
likely “become firmly established within the ever-expanding, evidence-based context
of cognitive-behavioral therapy” (p. 314).
A strength of the behavioral approaches is the emphasis on ethical accountabil-
ity. Behavior therapy is ethically neutral in that it does not dictate whose behavior
or what behavior should be changed. At least in cases of voluntary counseling, the
behavioral practitioner only specifies how to change those behaviors the client tar-
gets for change. Clients have a good deal of control and freedom in deciding what
the goals of therapy will be. A collaborative therapist–client relationship is an essen-
tial aspect of behavior therapy. Because clients are active in selecting goals and pro-
cedures in the therapy process and are applying what they are learning in therapy
to daily life, the chance that they will become the target of unethical behavior is
decreased (Speigler, 2016).
Limitations and Criticisms of Behavior Therapy
Behavior therapy has been criticized for a variety of reasons. Let’s examine four
common criticisms and misconceptions people often have about behavior therapy,
together with my reactions.
Behavior therapy may change behaviors, but it does not change feelings. Some
critics argue that feelings must change before behavior can change. Behavioral
practitioners hold that empirical evidence has not shown that feelings must be
changed first, and behavioral clinicians do in actual practice deal with feelings as
an overall part of the treatment process. A general criticism of both the behavioral
and the cognitive approaches is that clients are not encouraged to experience their
emotions. In concentrating on how clients are behaving or thinking, some behavior
therapists tend to play down the working through of emotional issues. Generally,
I favor initially focusing on what clients are feeling and then working with the
behavioral and cognitive dimensions. When clients’ feelings are engaged, this seems
to me to be a good point of departure. I can still tie a discussion of what clients are
feeling with how this is affecting their behavior, and I can later inquire about their
cognitions.
Behavior therapy does not provide insight. If this assertion is indeed true,
behavior therapists would probably respond that insight is not a necessary requisite
for behavior change. Follette and Callaghan (2011) state that contemporary behavior
therapists tend to be leery of the role of insight in favor of alterable, controllable,
causal variables. It is possible for therapy to proceed without a client knowing how
change is taking place. Although change may be taking place, clients often cannot
explain precisely why. Furthermore, insights may result after clients make a change
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B E H A v I o R T H E R A P y 265
in behavior. Behavioral shifts often lead to a change in understanding or to insight,
which may lead to emotional changes as well.
Behavior therapy treats symptoms rather than causes. The psychoanalytic
assumption is that early traumatic events are at the root of present dysfunction.
Behavior therapists may acknowledge that deviant responses have historical origins,
but they contend that history is less important in the maintenance of current
problems than environmental events such as antecedents and consequences. However,
behavior therapists emphasize changing current environmental circumstances to
change behavior.
Related to this criticism is the notion that unless historical causes of present
behavior are therapeutically explored new symptoms will soon take the place of
those that were “cured.” Behaviorists rebut this assertion on both theoretical and
empirical grounds. They contend that behavior therapy directly changes the main-
taining conditions of problem behaviors (symptoms), thereby indirectly changing
the problem behaviors. Furthermore, they assert that there is no empirical evidence
that symptom substitution occurs after behavior therapy has successfully elimi-
nated unwanted behavior because they have changed the conditions that give rise to
those behaviors (Spiegler, 2016).
Behavior therapy involves control and social influence by the therapist. All
therapists have a power relationship with the client and thus therapy involves
social influence; the ethical issue relates to the therapist’s degree of awareness of
this influence and how it is addressed in therapy. Behavior therapy recognizes the
importance of making the social influence process explicit, and it emphasizes client-
oriented behavioral goals. Therapy progress is continually assessed and treatment is
modified to ensure that the client’s goals are being met.
Behavior therapists address ethical issues by stating that therapy is basically a
psychoeducational process. At the outset of behavior therapy, clients learn about the
nature of counseling, the procedures that may be employed, and the benefits and
risks. Clients are given information about the specific therapy procedures appropri-
ate for their particular problems. To some extent, they also participate in the choice
of techniques that will be used in dealing with their problems. With this informa-
tion clients become informed, genuine partners in the therapeutic venture.
The literature in the field of behavior therapy is so extensive and diverse that it is
not possible in one brief survey chapter to present a comprehensive, in-depth discus-
sion of behavioral concepts and techniques. Examining some of the suggested read-
ings at the end of this chapter will further your knowledge of this complex approach.
Self-Reflection and Discussion Questions
1. Behavior therapists use a brief, active, directive, collaborative, present-
focused, didactic, psychoeducational model of therapy that relies on
empirical validation of its concepts and techniques. What do you see as
the main strengths and limitations of this focus?
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266 C H A P T E R N I N E
2. What are some unique characteristics common to all of the behavioral
therapies? How do you see these therapies as being able to apply to a
setting in which you might work?
3. The third-generation behavioral approaches involve mindfulness and
acceptance-based concepts. What aspects of these concepts would you
most want to incorporate in your work with clients?
4. How can you apply mindfulness techniques in your daily life? What
value do you place on becoming more mindful?
5. What are some of the behavioral interventions that you can see yourself
applying to your personal life? What specific behavioral techniques do
you most want to incorporate into your counseling practice?
Where to Go From Here
Visit CengageBrain,com or watch the DVD program Integrative Counseling: The Case
of Ruth and Lecturettes, Session 8 (“Behavioral Focus in Counseling”), in which I dem-
onstrate a behavioral way to assist Ruth in developing an exercise program. It is
crucial that Ruth makes her own decisions about specific behavioral goals she wants
to pursue. This applies to my attempts to work with her in developing methods of
relaxation, increasing her self-efficacy, and designing an exercise plan.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Antony, M. M. (2009). Behavioral Therapy Over Time (APA Psychotherapy
Video Series)
Hayes, S. C. (2011). Acceptance and Commitment Therapy (Systems of Psycho-
therapy Video Series)
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on behavior therapy. New video and editorial con-
tent is made available monthly. DVDs relevant to this chapter are available at www
.psychotherapy.net and include the following:
Stuart, R. (1998). Behavioral Couples Therapy (Couples Therapy With the
Experts Series)
If you have an interest in further training in behavior therapy, the Association
for Behavioral and Cognitive Therapies (ABCT) is an excellent resource. ABCT (for-
merly AABT) is a membership organization of more than 4,500 mental health pro-
fessionals and students who are interested in behavior therapy, cognitive behavior
therapy, behavioral assessment, and applied behavioral analysis. Members receive
discounts on all ABCT publications, some of which are:
�� Directory of Graduate Training in Behavior Therapy and Experimental-Clinical
Psychology is an excellent source for students and job seekers who want
information on programs with an emphasis on behavioral training.
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B E H A v I o R T H E R A P y 267
�� Directory of Psychology Internships: Programs Offering Behavioral Training
describes training programs having a behavioral component.
�� Behavior Therapy is an international quarterly journal focusing on origi-
nal experimental and clinical research, theory, and practice.
�� Cognitive and Behavioral Practice is a quarterly journal that features clini-
cally oriented articles.
Full and associate memberships are $199 and include one journal subscription
(to either Behavior Therapy or Cognitive and Behavioral Practice) and a subscription to
the Behavior Therapist (a newsletter with feature articles, training updates, and asso-
ciation news). Membership also includes reduced registration and continuing edu-
cation course fees for ABCT’s annual convention held in November, which features
workshops, master clinician programs, symposia, and other educational presenta-
tions. Student memberships are $49.
Association for Behavioral and Cognitive Therapies
www.abct.org
Mindfulness and Acceptance-Based Approaches
If you are interested in finding out more about mindfulness and acceptance-based
programs and resources for the newer therapies, explore some of these websites:
Institute for Meditation and Psychotherapy
www.meditationandpsychotherapy.org
Mindfulness-Based Stress Reduction
www.umassmed.edu/cfm
Dialectical Behavior Therapy
www.behavioraltech.com
Acceptance and Commitment Therapy
www.acceptanceandcommitmenttherapy.com
Self-Compassion Resources
www.self-compassion.org
Recommended Supplementary Readings
Behavior Therapy (Antony & Roemer, 2011a) offers
a useful and updated overview of behavior therapy.
Contemporary Behavior Therapy (Spiegler, 2016) is a
comprehensive discussion of basic principles and
applications of the behavior therapies. It is an excel-
lent text that is based on research.
Interviewing and Change Strategies for Helpers (Corm-
ier, Nurius, & Osborn, 2013) is a comprehensive
and clearly written textbook dealing with training
experiences and skill development. This book offers
practitioners a wealth of material on a variety of
topics, such as assessment procedures, selection of
goals, development of appropriate treatment pro-
grams, and methods of evaluating outcomes.
Mindfulness and Psychotherapy (Germer, Siegel, & Ful-
ton, 2013) is a practical introduction to mindfulness
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268 C H A P T E R N I N E
and its clinical applications. This edited work
addresses the basics of mindfulness meditation, the
centrality of the therapeutic relationship, and ways
that cultivating mindfulness can enhance accep-
tance and empathy.
Wisdom and Compassion in Psychotherapy: Deepening
Mindfulness in Clinical Practice (Germer & Siegel,
2012) is an edited book that expands on the mes-
sage that we need to treat ourselves as we would
want other to treat us. There are some excellent
contributed chapters that discuss the meaning of
wisdom and demonstrate the clinical applications
inherent in blending Western psychotherapy and
Buddhist psychology.
Sitting Together: Essential Skills for Mindfulness-Based
Psychotherapy (Pollak, Pedulla, & Siegel, 2014) is a
very useful resource for introducing mindfulness
into the practice of psychotherapy. This clearly writ-
ten book features practical meditation exercises that
can enhance the therapy process and demonstrates
the power of mindful presence for therapists and
their clients.
Mindfulness-Based Cognitive Therapy for Depression
(Segal, Williams, & Teasdale, 2013) is an excellent
resource for those who are interested in learning
about the fundamentals and clinical applications of
mindfulness-based cognitive therapy, especially in
working with depression.
Acceptance and Mindfulness in Cognitive Behavior
Therapy: Understanding and Applying the New Therapies
(Herbert & Forman, 2011) is one of the best
resources for discussion of new developments in
behavior therapy and future trends.
The Mindfulness Solution: Everyday Practices for Everyday
Problems (Siegel, 2010) is an outstanding practical guide
in applying mindfulness practices to living a meaning-
ful life, as well as a guide for practitioners who wish to
teach clients how to use mindfulness in meeting life’s
challenges. This is a well-written book that highlights
applications to personal and professional areas.
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269
10Cognitive Behavior Therapy
1. Identify common attributes
shared by all cognitive behavior
approaches.
2. Describe how the A-B-C model
is a way of understanding the
interaction among feelings,
thoughts, and behavior.
3. Understand how cognitive
methods can be applied to change
thinking and behavior.
4. Understand the unique
contributions of Aaron Beck to the
development of cognitive therapy.
5. Identify the basic principles of
cognitive therapy.
6. Describe the basic principles of
strengths-based CBT.
7. Understand Meichenbaum’s
three-phase process of behavior
change.
8. Describe the key concepts and
phases of Meichenbaum’s stress
inoculation training.
9. Identify the strengths and
limitations of cognitive behavior
therapy from a multicultural
perspective.
10. Differentiate REBT from CT with
respect to how faulty beliefs are
explored in therapy.
11. Know some of the main differences
in how Ellis, Beck, Padesky, and
Meichenbaum apply CBT in
practice.
L e a r n i n g O b j e c t i v e s
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270 C H A P T E R T E N
Introduction
As you saw in Chapter 9, traditional behavior therapy has broadened and
largely moved in the direction of cognitive behavior therapy. Several of the more
prominent cognitive behavioral approaches are featured in this chapter, including
Albert Ellis’s rational emotive behavior therapy (REBT), Aaron T. Beck and Judith
Beck’s cognitive therapy (CT), Christine Padesky’s strengths-based CBT (SB-CBT),
and Donald Meichenbaum’s cognitive behavior therapy. These approaches all fall
under the general umbrella of cognitive behavior therapies (CBT).
All of the cognitive behavioral approaches share the same basic characteristics
and assumptions as traditional behavior therapy (see Chapter 9). Although the
approaches are quite diverse, they do share these attributes: (1) a collaborative rela-
tionship between client and therapist, (2) the premise that psychological distress
is often maintained by cognitive processes, (3) a focus on changing cognitions to
produce desired changes in affect and behavior, (4) a present-centered, time-limited
focus, (5) an active and directive stance by the therapist, and (6) an educational
treatment focusing on specific and structured target problems (A. Beck & Weishaar,
2014). In addition, both cognitive therapy and the cognitive behavioral therapies
are based on a structured psychoeducational model, make use of homework, place
responsibility on the client to assume an active role both during and outside ther-
apy sessions, emphasize developing a strong therapeutic alliance, and draw from
a variety of cognitive and behavioral strategies to bring about change. Therapists
help clients examine how they understand themselves and their world and suggest
ways clients can experiment with new ways of behaving (Dienes, Torres-Harding,
Reinecke, Freeman, & Sauer, 2011).
To a large degree, both cognitive therapy and cognitive behavior therapy are based
on the assumption that beliefs, behaviors, emotions, and physical reactions are all
reciprocally linked. Changes in one area lead to changes in the other areas. A change
in beliefs is not the only target of therapy, but enduring changes usually require a
change in beliefs. CBT therapists apply behavioral techniques such as operant condi-
tioning, modeling, and behavioral rehearsal to the more subjective processes of think-
ing and internal dialogue. In addition, therapists help clients actively test their beliefs
in therapy, on paper, and through behavioral experiments. Cognitive therapy and the
cognitive behavioral approaches include a variety of behavioral strategies (discussed in
Chapter 9) as well as cognitive strategies as a part of their integrative repertoire.
Visit CengageBrain.com or watch the DVD video program on Chapter 10, Theory and Practice
of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the brief
lecture for each chapter prior to reading the chapter.
Albert Ellis’s Rational Emotive Behavior Therapy
Introduction
rational emotive behavior therapy (REBT) was the first of the cognitive behav-
ior therapies, and today it continues to be a major cognitive behavioral approach.
REBT has a great deal in common with the therapies that are oriented toward
LO1
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C o g N I T I V E B E H A V I o R T H E R A P y 271
cognition and behavior as it also emphasizes thinking, assessing, deciding, analyz-
ing, and doing. A basic assumption of REBT is that people contribute to their own
psychological problems, as well as to specific symptoms, by the rigid and extreme
beliefs they hold about events and situations. REBT is based on the assumption
that cognitions, emotions, and behaviors interact significantly and have a reciprocal
cause-and-effect relationship. REBT has consistently emphasized all three of these
modalities and their interactions, thus qualifying it as a holistic and integrative
approach (A. Ellis & Ellis, 2011, 2014; D. Ellis, 2014).
Although REBT is generally conceded to be the parent of today’s cognitive
behavioral approaches, it was preceded by earlier schools of thought. Ellis gave credit
to Alfred Adler as an influential precursor of REBT, and Karen Horney’s (1950) ideas
on the “tyranny of the shoulds” are apparent in the conceptual framework of REBT.
Ellis also acknowledged his debt to some of the Eastern philosophies and the ancient
Greeks, especially the Stoic philosopher Epictetus, who said around 2,000 years ago:
ALBERT ELLIS (1913–2007) was born in
Pittsburgh but escaped to the wilds of
New York at the age of 4 and lived there
(except for a year in New Jersey) for the
rest of his life. He was hospitalized nine
times as a child, mainly with nephritis,
and developed renal glycosuria at the
age of 19 and diabetes at the age of 40.
Despite his many physical challenges,
he lived an unusually robust, active, and
energetic life until his death at age 93.
As he put it, “I am busy spreading the
gospel according to St. Albert.”
Realizing that he could counsel people skillfully
and that he greatly enjoyed doing so, Ellis decided to
become a psychologist. Believing psychoanalysis to be
the deepest form of psychotherapy, Ellis was analyzed
and supervised by a training analyst. He then practiced
psychoanalytically oriented psychotherapy, but even-
tually he became disillusioned with the slow progress
of his clients. He observed that they improved more
quickly once they changed their ways of thinking
about themselves and their problems. Early in 1955
he developed an approach to psychotherapy he called
rational therapy and later rational emotive therapy,
and which is now known as rational emotive behavior
therapy (REBT). Ellis has rightly been referred to as
the grandfather of cognitive behavior therapy.
To some extent Ellis developed his approach as
a method of dealing with his own problems during
his youth. At one point in his life, for example, he had
exaggerated fears of speaking in public. During his
adolescence he was extremely shy around
young women. At age 19 he forced him-
self to talk to 100 different women in the
Bronx Botanical Gardens over a period of
one month. Although he never managed
to get a date from these brief encounters,
he does report that he desensitized himself
to his fear of rejection by women. By apply-
ing rational and behavioral methods, he
managed to conquer some of his strongest
emotional blocks (A. Ellis, 1994, 1997).
People who heard Ellis lecture often
commented on his abrasive, humorous,
and flamboyant style. In his workshops it seemed
that he took delight in giving vent to his eccentric
side, such as peppering his speech with four-letter
words. He greatly enjoyed his work and teaching
REBT, which was his passion and primary commit-
ment in life. He gave workshops wherever he went
in his travels and had proclaimed, “I wouldn’t go to
the Taj Mahal unless they asked me to do a work-
shop there!”
Ellis married Australian psychologist Debbie
Joffe in November 2004, whom he has called “the
greatest love of my life” (A. Ellis, 2008). They shared
the same life goals and ideals, and they worked as
a team presenting workshops. If you are interested
in learning more about the life and work of Albert
Ellis, I recommend two of his books: Rational Emo-
tive Behavior Therapy: It Works for Me—It Can Work for
You (A. Ellis, 2004a) and All Out! An Autobiography
(A. Ellis, 2010).
Albert Ellis
Ph
ot
o
Co
ur
te
sy
o
f A
lb
er
t E
lli
s
In
st
itu
te
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272 C H A P T E R T E N
“People are disturbed not by events, but by the views which they take of them”
(as cited in A. Ellis, 2001a, p. 16). Ellis’s reformulation of Epictetus’s dictum can be
stated as, “People disturb themselves as a result of the rigid and extreme beliefs they
hold about events more than the events themselves.”
REBT’s basic hypothesis is that our emotions are mainly created from our
beliefs, which influence the evaluations and interpretations we make and fuel
the reactions we have to life situations. Through the therapeutic process, cli-
ents are taught skills that give them the tools to identify and dispute irrational
beliefs that have been acquired and self-constructed and are now maintained by
self-indoctrination. They learn how to replace such detrimental ways of think-
ing with effective and rational cognitions, and as a result they change their
emotional experience and their reactions to situations. The therapeutic process
allows clients to apply REBT principles for change not only to a particular pre-
senting problem but also to many other problems in life or future problems they
might encounter.
A large part of the therapy is seen as an educational process. The therapist func-
tions in many ways like teacher, collaborating with the client on homework assign-
ments and introducing strategies for constructive thinking. The client is the learner
who then practices these new skills in everyday life.
Key Concepts
View of Emotional Disturbance
REBT is based on the premise that we learn irrational beliefs from significant others
during childhood and then re-create these irrational beliefs throughout our life-
time. We actively reinforce our self-defeating beliefs through the processes of auto-
suggestion and self-repetition, and we then behave in ways that are consistent with
these beliefs. Hence, it is largely our own repetition of early-indoctrinated irrational
beliefs, rather than a parent’s repetition, that keeps dysfunctional attitudes alive
and operative within us.
Ellis asserted that blame can be at the core of many emotional disturbances. If
we want to become psychologically healthy, we had better stop blaming ourselves
and others and learn to fully and unconditionally accept ourselves despite our
imperfections. Ellis (A. Ellis & Blau, 1998; A. Ellis & Harper, 1997; A. Ellis & Ellis,
2011) hypothesizes that we have strong tendencies to transform our desires and
preferences into dogmatic “shoulds,” “musts,” “oughts,” demands, and commands.
When we are feeling disturbed, it is a good idea to look to our hidden dogmatic
“musts” and absolutist “shoulds.” Such demands create disruptive feelings and dys-
functional behaviors (A. Ellis, 2001a, 2004a).
Here are three basics musts (or irrational beliefs) we internalize that inevitably lead
to self-defeat (A. Ellis & Ellis, 2011):
1. “I must do well and be loved and approved by others.”
2. “Other people must treat me fairly, kindly, and well.”
3. “The world and my living conditions must be comfortable, gratifying,
and just, providing me with all that I want in life.”
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C o g N I T I V E B E H A V I o R T H E R A P y 273
We have a strong tendency to make and keep ourselves emotionally disturbed by
internalizing and perpetuating self-defeating beliefs such as these, which is one
reason it is a real challenge to achieve and maintain good psychological health
(A. Ellis, 2001a, 2001b).
A-B-C Framework
The A-B-C framework is central to REBT theory and practice. This model
provides a useful tool for understanding the client’s feelings, thoughts, events, and
behavior (A. Ellis & Ellis, 2011). A is the existence of an activating event or adversity, or
an inference about an event by an individual. C is the emotional and behavioral conse-
quence or reaction of the individual; the reaction can be either healthy or unhealthy. A
(the activating event) does not cause C (the emotional consequence). Instead, B, which
is the person’s belief about A, largely creates C, the emotional reaction.
If a person experiences depression after a divorce, for example, it may not be
the divorce itself that causes the depressive reaction, nor his inference that he has
failed, but the person’s beliefs about his divorce or about his failure (D. Ellis, 2014).
Ellis maintains that the beliefs about the rejection and failure (at point B) are what
mainly cause the depression (at point C)—not the actual event of the divorce or the
person’s inference of failure (at point A). Believing that human beings are largely
responsible for creating their own emotional reactions and disturbances, and show-
ing people how they can change their irrational beliefs that directly “cause” their
disturbed emotional consequences, is at the heart of REBT (A. Ellis & Ellis, 2011; A.
Ellis & Harper, 1997).
After A, B, and C comes D (disputing). Essentially, D encompasses methods that
help clients challenge their irrational beliefs. There are three components of this dis-
puting process: detecting, debating, and discriminating. Clients learn to discriminate
irrational (self-defeating) beliefs from rational (self-helping) beliefs (A. Ellis & Ellis,
2011). Once they can detect irrational beliefs, particularly absolutistic “shoulds” and
“musts,” “awfulizing,” and “self-downing,” clients debate dysfunctional beliefs by
logically, empirically, and pragmatically questioning them. Clients are asked to vig-
orously argue themselves out of believing and acting on irrational beliefs. Although
REBT uses many other cognitive, emotive, and behavioral methods to help clients
minimize their irrational beliefs, it emphasizes the process of vigorously disputing
(D) such beliefs both during therapy sessions and in everyday life. Following that,
clients are encouraged to develop E, a new effective philosophy, which also has a
practical side. A new and effective belief system consists of replacing unhealthy irra-
tional thoughts with healthy rational ones. “Homework” can enhance and maintain
these therapeutic gains and personal insights.
The Therapeutic Process
Therapeutic Goals
The many roads taken in rational emotive behavior therapy lead toward the destina-
tion of clients minimizing their emotional disturbances and self-defeating behav-
iors by acquiring a more realistic, workable, and compassionate philosophy of life.
LO2
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274 C H A P T E R T E N
The therapeutic process of REBT involves a collaborative effort between therapist
and client to choose realistic and life-enhancing therapeutic goals. The therapist’s
task is to help clients differentiate between realistic and unrealistic goals and also
between self-defeating and life-enhancing goals. A basic aim is to teach clients how
to change their dysfunctional emotions and behaviors into healthy ones. According
to Ellis and Ellis (2011) another goal of REBT is to assist clients in the process of
achieving unconditional self-acceptance (USA), unconditional other-acceptance (UOA), and
unconditional life-acceptance (ULA). As clients become more able to accept themselves,
they are more likely to unconditionally accept others and to accept life as it is. A
famous saying of Ellis (A. Ellis & Ellis, 2011) is: “Life has inevitable suffering as well
as pleasure. By realistically thinking, feeling, and acting to enjoy what you can, and
unangrily and unwhiningly accepting painful aspects that cannot be changed, you
open yourself to much joy” (p. 48).
Therapist’s Function and Role
The therapist has specific tasks, and the first step is to show clients how they have
incorporated many irrational absolute “shoulds,” “oughts,” and “musts” into their
thinking. The therapist disputes clients’ irrational beliefs and encourages clients to
engage in activities that will counter their self-defeating beliefs by replacing their
rigid “musts” with preferences.
A second step in the therapeutic process is to demonstrate how clients are keep-
ing their emotional disturbances active by continuing to think illogically and unre-
alistically. In other words, when clients keep reindoctrinating themselves, they create
their own psychological problems. Ellis reminds us that we are responsible for our
own emotional destiny (A. Ellis, 2004b, 2010).
To get beyond mere recognition of irrational thoughts, the therapist takes a
third step—helping clients change their thinking and minimize their irrational ideas.
Although it may be unlikely that we can entirely eliminate the tendency to think irra-
tionally, we can make ongoing efforts to reduce the frequency of such thinking. The
therapist encourages clients to identify the irrational beliefs they have unquestion-
ingly accepted, demonstrates how they are continuing to indoctrinate themselves
with these beliefs, and reminds them that change is possible with persistent effort.
The fourth step in the therapeutic process is to strongly encourage clients to
develop a rational philosophy of life so that in the future they can avoid hurting
themselves again by believing other irrational beliefs. Tackling only specific prob-
lems or symptoms can give no assurance that new disabling fears will not emerge.
It is desirable, then, for the therapist to dispute the core irrational thinking and to
teach clients how to substitute rational beliefs and healthy behaviors for irrational
beliefs and self-defeating behaviors.
Client’s Experience in Therapy
The therapeutic process largely focuses on clients’ experiences in the present. Like
the person-centered and existential approaches to therapy, REBT emphasizes here-
and-now experiences and clients’ present ability to change the patterns of think-
ing and emoting that they constructed earlier. The therapist may not devote much
time to exploring clients’ early history and making connections between their past
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C o g N I T I V E B E H A V I o R T H E R A P y 275
and present behavior unless doing so will aid the therapeutic process. REBT differs
from many other therapeutic approaches in that it does not place much value on
free association, working with dreams, or dealing with transference phenomena.
Ellis and Ellis (2014) maintain that transference is not encouraged, and when it
does occur, the therapist is likely to confront it because it is generally based on the
client’s dire need to be liked and approved of by the therapist. Any unhealthy needi-
ness clients display can be counterproductive and foster dependence on approval
from the therapist.
Clients are encouraged to actively work outside therapy sessions. By carrying out
behavioral homework assignments, clients become increasingly proficient at mini-
mizing irrational thinking and disturbances in feeling and behaving. Homework
is carefully designed and agreed upon and is aimed at getting clients to carry out
productive actions that contribute to emotional and attitudinal change. These
assignments are checked in later sessions, and clients continue to focus on learning
effective ways to dispute self-defeating thinking. Toward the end of therapy, clients
review their progress, make plans, and identify strategies to prevent, or cope with,
any new challenges as they arise.
Relationship Between Therapist and Client
Because REBT is a cognitive and directive behavioral process, a warm relation-
ship between therapist and client is not required, but it may enhance the process
for some. At the very least, a respectful relationship is recommended. As with the
person-centered therapy of Rogers, REBT practitioners strive to unconditionally
accept all clients and to teach them to unconditionally accept others and them-
selves. The therapist takes the mystery out of the therapeutic process, teaching
clients about the cognitive hypothesis of disturbance and helping clients under-
stand how they are continuing to sabotage themselves and what they can do to
change. Insight alone does not typically lead to psychotherapeutic change, action
is also required. The therapist frequently acknowledges any progress clients have
made due to their own efforts. REBT practitioners accept their clients (and them-
selves!) as imperfect beings who can be helped through a variety of techniques
including teaching, bibliotherapy, and behavior modification (A. Ellis & Ellis,
2011, 2014; D. Ellis, 2014).
Application: Therapeutic Techniques and Procedures
The Practice of Rational Emotive Behavior Therapy
Rational emotive behavior therapists are multimodal and integrative. REBT prac-
titioners use a number of different modalities (cognitive, emotive, behavioral, and
interpersonal) to dispel self-defeating cognitions and to teach people how to acquire
a rational approach to living. Therapists are encouraged to be flexible and creative
in their use of methods, making sure to tailor the techniques to the unique needs of
each client (A. Ellis & Ellis, 2011; D. Ellis, 2014).
For a concrete illustration of how Dr. Ellis works with the client Ruth drawing
from cognitive, emotive, and behavioral techniques, see Case Approach to Counseling
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276 C H A P T E R T E N
and Psychotherapy (Corey, 2013, chap. 8). What follows is a brief summary of the
major cognitive, emotive, and behavioral techniques Ellis describes (A. Ellis, 2004a;
A. Ellis & Crawford, 2000; A. Ellis & Ellis, 2011).
Cognitive Methods REBT practitioners usually incorporate a persuasive
cognitive methodology in the therapeutic process. They demonstrate to clients, often
in a quick and direct manner, what it is that they are continuing to tell themselves.
Then they teach clients how to challenge these self-statements so that they no longer
believe them, encouraging them to acquire a philosophy based on facts. REBT relies
heavily on thinking, disputing, debating, challenging, interpreting, explaining, and
teaching. The most efficient way to bring about lasting emotional and behavioral
change is for clients to change their way of thinking (A. Ellis & Ellis, 2011, 2014).
Here are some cognitive techniques available to the therapist.
�� Disputing irrational beliefs. The most common cognitive method of REBT
consists of the therapist actively disputing clients’ irrational beliefs and
teaching them how to do this challenging on their own. Clients dispute
a particular “must,” absolute “should,” or “ought” until they no longer
hold that irrational belief, or at least until it is diminished in strength.
Here are some examples of questions or statements clients learn to tell
themselves when they dispute their irrational ideas: “Why must people
treat me fairly?” “How do I become a total flop if I don’t succeed at
important tasks I try?” “If I don’t get the job I want, it may be disap-
pointing, but I can certainly stand it.” “If life doesn’t always go the way
I would like it to, it isn’t awful, just inconvenient.”
�� Doing cognitive homework. REBT clients are expected to make lists of their
problems, look for their absolutist beliefs, and dispute these beliefs.
Clients are encouraged to record and think about how their beliefs
contribute to their personal problems and are asked to work hard at
uprooting these self-defeating cognitions. Homework assignments are a
way of tracking down and attending to the “shoulds” and “musts” that
are part of their internalized self-messages. In this way, clients gradu-
ally learn to lessen anxiety and to challenge basic irrational thinking.
They often fill out the REBT Self-Help Form, which is reproduced in
the Student Manual for Theory and Practice of Counseling and Psychotherapy
(Corey, 2017). Their comments on this form can focus therapy sessions
as they critically evaluate the disputation of their beliefs. Clients may be
encouraged to put themselves in risk-taking situations that will allow
them to challenge self-limiting beliefs. For example, a client with a tal-
ent for acting who is afraid to act in front of an audience because of fear
of failure may be asked to take a small part in a stage play. Work in the
therapy session can be designed so that out-of-session tasks are feasible
and the client has the skills to complete these tasks. Making changes
tends to be hard work. Doing work outside sessions is of real value in
revising clients’ thinking, feeling, and behaving.
�� Bibliotherapy. REBT, and other CBT approaches, can utilize biblio-
therapy as an adjunctive form of treatment. There are advantages of
LO3
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C o g N I T I V E B E H A V I o R T H E R A P y 277
bibliotherapy, such as cost-effectiveness, widespread availability, and the
potential of reaching a broad spectrum of populations. Bibliotherapeu-
tic approaches have empirical support for a range of clinical problems,
including the treatment of depression and many anxiety disorders
(Jacobs, 2008). Because therapy is seen as an educational process, clients
are encouraged to read REBT self-help books such as Rational Emotive
Behavior Therapy: It Works for Me—It Can Work for You (A. Ellis, 2004a) and
other books by Ellis (1999, 2000, 2001a, 2001b, 2005, 2010; A. Ellis &
Ellis, 2011).
�� Changing one’s language. REBT rests on the premise that imprecise lan-
guage is one of the causes of distorted thinking processes. Clients
learn that “musts,” “oughts,” and absolute “shoulds” can be replaced
by preferences. Instead of saying “It would be absolutely awful if …” they
learn to say “It would be inconvenient if …” Clients who use language
patterns that reflect helplessness and self-condemnation can learn to
employ new self-statements, which help them think and behave differ-
ently. As a consequence, they also begin to feel differently.
�� Psychoeducational methods. REBT programs introduce clients to various edu-
cational materials such as books, DVDs, and articles. Therapists educate
clients about the nature of their problems and how treatment is likely to
proceed. They ask clients how particular concepts apply to them. Clients
are more likely to cooperate with a treatment program if they understand
how the therapy process works and if they understand why particular
techniques are being used (Ledley, Marx, & Heimberg, 2010).
Emotive Techniques REBT practitioners use a variety of emotive procedures,
including unconditional acceptance, rational emotive role playing, modeling,
rational emotive imagery, and shame-attacking exercises. These emotive techniques
tend to be vivid and evocative in nature, and their purpose is to dispute clients’
irrational beliefs. These strategies are used both during the therapy sessions and
as homework assignments in daily life. Their purpose is not simply to provide a
cathartic experience but to help clients change some of their thoughts, emotions,
and behaviors (A. Ellis, 2001b; A. Ellis & Ellis, 2011). Let’s look at some of these
evocative and emotive therapeutic techniques in more detail.
�� Rational emotive imagery. This is a form of intense mental practice
designed to establish new emotional patterns in place of disrup-
tive ones by thinking in healthy ways (see A. Ellis, 2001a, 2001b).
In rational emotive imagery (rei), clients are asked to vividly
imagine one of the worst things that might happen to them and to
describe their disturbing feelings. Clients are shown how to train
themselves to develop healthy emotions, and as their feelings about
adversities change, they stand a better chance of changing their
behavior in the situation. This technique can be usefully applied to
interpersonal and other situations that are problematic for the indi-
vidual. Clients who practice rational emotive imagery several times
a week for a few weeks may reach the point where they no longer
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278 C H A P T E R T E N
feel upset over these negative events (A. Ellis, 2001a; A. Ellis & Ellis,
2011; D. Ellis, 2014).
�� Humor. Ellis contends that emotional disturbances often result from
taking oneself too seriously. He wrote hundreds of “Rational Humor-
ous Songs” (A. Ellis, 2005) and often led attendees at his workshops
in singing them. One appealing aspect of REBT is that it fosters the
development of a better sense of humor and helps put life into healthy
perspective (A. Ellis 2004a, 2010). Humor has both cognitive and
emotional benefits in bringing about change. Humor shows the absur-
dity of certain ideas that clients steadfastly maintain, and it teaches
clients to laugh—not at themselves but at their self-defeating ways of
thinking.
�� Role playing. Role playing has emotive, cognitive, and behavioral com-
ponents. The therapist may interrupt to show clients what they are
telling themselves to create their disturbances and what they can do to
change unhealthy feelings to healthy ones. Clients can rehearse certain
roles to bring out what they feel in a situation. For example, Dawson
may put off applying to a graduate school because he is afraid he won’t
be accepted. Just the thought of not being accepted to the school of
his choice brings out intense feelings of shame for “being stupid.” The
focus is on working through underlying irrational beliefs related to his
unpleasant feelings. Dawson role-plays an interview with the dean of
graduate students, notes his anxiety and the specific beliefs leading to
it, and challenges his conviction that he absolutely must be accepted
and that not gaining such acceptance means that he is a stupid and
incompetent person.
�� Shame-attacking exercises. Ellis developed exercises to help people reduce
shame and anxiety over behaving in certain ways. He asserts that we
can stubbornly refuse to feel ashamed by telling ourselves that it is
not catastrophic if someone thinks we are foolish. Practicing shame-
attacking exercises can reduce, minimize, and prevent feelings of
shame, guilt, anxiety, and depression (A. Ellis, 1999, 2000, 2001a,
2001b, 2005, 2010; A. Ellis & Ellis, 2011, 2014). The exercises are aimed
at increasing self-acceptance and mature responsibility, as well as
helping clients see that much of what they think of as being shameful
has to do with the way they define reality for themselves. Clients may
take the risk of doing something that they are ordinarily afraid to do
because of what others might think. Through homework practice, cli-
ents eventually learn that they can choose not to let others’ reactions
or possible disapproval stop them from doing the things they would
like to do. For example, clients may wear “loud” clothes designed to
attract attention, sing loudly, ask a silly question at a lecture, or ask
for a left-handed monkey wrench in a grocery store. By carrying out
such assignments, clients are likely to find out that other people are
not really that interested in their behavior. Note that these exercises do
not involve illegal activities or acts that will be harmful to oneself, to
others, or that will unduly alarm other people!
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C o g N I T I V E B E H A V I o R T H E R A P y 279
Behavioral Techniques REBT practitioners use most of the standard behavior
therapy procedures, especially operant conditioning, self-management principles,
systematic desensitization, relaxation techniques, and modeling. Behavioral homework
assignments carried out in real-life situations are particularly important. These
assignments are done systematically and are recorded and analyzed. Homework gives
clients opportunities to practice new skills outside of the therapy session, which may
be even more valuable for clients than work done during the therapy hour (Ledley et al.,
2010). Doing homework may involve in-vivo desensitization (A. Ellis & Ellis, 2011) and
live exposure in daily life situations. Clients actually do new and difficult things, and in
this way they put their insights to use in the form of concrete action. Acting differently
helps them incorporate functional beliefs.
Applications of REBT as a Brief Therapy
Ellis originally developed REBT to try to make psychotherapy more efficient than
other systems of therapy. He maintained that the best and most effective therapy
quickly teaches clients how to tackle present as well as future problems. REBT is
well suited as a brief form of therapy, whether it is applied to individuals, groups,
couples, or families. Clients learn self-therapy techniques that they can continue to
apply through their own ongoing work and practice (A. Ellis & Ellis, 2011).
Application to Group Counseling
Cognitive behavior therapy (CBT) groups are among the most popular treatments
in clinics and community agency settings. One of the most common CBT group
approaches is based on REBT principles and techniques. REBT practitioners employ
an active role in encouraging members to commit themselves to practicing what
they are learning in the group sessions in everyday life. What goes on during the
group is valuable, but therapists know that consistent work between group sessions
and after a group ends is crucial. The group context provides members with tools
they can use to become self-reliant and to accept themselves, and others, uncondi-
tionally as they encounter new problems in daily living.
In group therapy, members are taught how to apply REBT principles to one
another. Ellis recommends that some clients experience group therapy as well
as individual therapy. Group members (1) learn how their beliefs influence what
they feel and what they do, (2) explore ways to change self-defeating thoughts in
various concrete situations, and (3) learn to minimize symptoms through a pro-
found change in their philosophy. Ellis and Ellis (2011, 2014) contend that group
REBT is frequently the treatment of choice because it affords many opportunities
to practice assertiveness skills, to take risks by practicing different behaviors, to
challenge self-defeating thinking, to learn from the experiences of others, and to
interact therapeutically and socially with each other in after-group sessions. All of
the cognitive, emotive, and behavioral techniques described earlier are applicable to
group counseling as are the techniques covered in Chapter 9 on behavior therapy.
Behavioral homework and skills training are just two useful methods for a group
format. For a more detailed discussion of REBT applied to group counseling, see
Corey (2016, chap. 14).
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280 C H A P T E R T E N
AARON TEMKIN BECK (b. 1921) was
born in Providence, Rhode Island. His
childhood, although happy, was inter-
rupted by a life-threatening illness when
he was 8 years old. As a consequence,
he experienced blood injury fears, fear
of suffocation, and anxiety about his
health. Beck used his personal problems
as a basis for understanding others and
for developing his cognitive theory.
A graduate of Brown University and
Yale School of Medicine, Beck initially was
trained as a neurologist, but he switched
to psychiatry during his residency. Beck attempted to
validate Freud’s theory of depression, but the results of
his research did not support Freud’s motivational model
and the explanation of depression as “anger turned
inward.” Beck set out to develop a model for depression
that fit with his empirical findings, and for many years
Beck endured isolation from and rejection by most of
his colleagues in the psychiatric community. Through
his research, Beck developed a cognitive theory of depres-
sion, which represented a new and comprehensive con-
ceptualization. He found the cognitions of depressed
individuals were characterized by errors in interpretation
that he called “cognitive distortions.” For Beck, negative
thoughts reflect underlying dysfunctional beliefs and
assumptions. When these beliefs are triggered by situ-
ational events, a depressive pattern is put in motion. Beck
believes clients can assume an active role in modifying
their dysfunctional thinking and thereby gain relief from
a range of psychiatric conditions. His continuous research
in the areas of psychopathology and the utility of cogni-
tive therapy eventually earned him a place of prominence
in the scientific community in the United States. Beck
is the founder of cognitive therapy (CT),
one of the most influential and empirically
validated approaches to psychotherapy. He
has won nearly every national and interna-
tional prize for his scientific contributions
to psychotherapy and suicide research and
was even short-listed for the Nobel Prize in
medicine.
Beck joined the Department of Psy-
chiatry of the University of Pennsylvania
in 1954, where he currently holds the posi-
tion of University Professor (Emeritus) of
Psychiatry. Beck has successfully applied
cognitive therapy to depression, generalized anxiety
and panic disorders, suicide, alcoholism and drug
abuse, eating disorders, marital and relationship prob-
lems, psychotic disorders, and personality disorders.
He has developed assessment scales for depression,
suicide risk, anxiety, self-concept, and personality.
He is the founder of the Beck Institute, which is
a research and training center directed by one of his
four children, Dr. Judith Beck. He has nine grand-
children and five great-grandchildren and has been
married for more than 60 years. To his credit, Aaron
Beck has focused on developing the cognitive therapy
skills of tens of thousands of clinicians throughout
the world. In turn, many of them have established
their own cognitive therapy centers. Beck has a vision
for the cognitive therapy community that is global,
inclusive, collaborative, empowering, and benevolent.
He continues to remain active in writing and research
and has published 24 books and more than 600 arti-
cles and book chapters. For more on the life of Aaron
T. Beck, see Aaron T. Beck (Weishaar, 1993) or “Aaron
T. Beck: Mind, Man and Mentor” (Padesky, 2004).
Aaron T. Beck
Co
ur
te
sy
o
f B
ec
k
In
st
itu
te
fo
r C
og
ni
tiv
e
Be
ha
vi
or
T
he
ra
py
,
Ba
la
C
yn
w
yd
, P
A
.
JUDITH S. BECK (b. 1954) was born
in Philadelphia, the second of four
children. Both her parents were quite
notable in their fields: her father, as
“the father of cognitive therapy,” and
her mother, as the first female judge
on the appellate court of the Common-
wealth of Pennsylvania. From an early
age, Beck wanted to be an educator, and
she began her professional career teach-
ing children with learning disabilities.
Her ability to break down complex sub-
jects into easily understandable ideas, so
critical in the education of children with
learning differences, is characteristic of
all her work.
Beck later returned to graduate
school, studied education and psychol-
ogy, and completed a postdoctoral fel-
lowship at the Center for Cognitive
Behavior Therapy at the University of
Pennsylvania. In 1994 she and her father Judith S. Beck
Co
ur
te
sy
o
f B
ec
k
In
st
itu
te
fo
r C
og
ni
tiv
e
Be
ha
vi
or
Th
er
ap
y,
B
al
a
Cy
nw
yd
, P
A
.
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C o g N I T I V E B E H A V I o R T H E R A P y 281
Aaron Beck’s Cognitive Therapy
Introduction
Aaron T. Beck developed cognitive therapy (CT) about the same time that
Ellis was developing REBT. They were not aware of each others’ work and created
their approaches independently. Ellis developed REBT based on philosophical
tenets, whereas Beck’s CT was based on empirical research (Padesky & Beck, 2003).
Like REBT, CT emphasizes education and prevention but uses specific methods tai-
lored to particular issues. The specificity of CT allows therapists to link assessment,
conceptualization, and treatment strategies.
Beck (A. Beck 1963, 1967) set out to create an evidence-based therapy for depres-
sion, and he tested each of his theoretical constructs with empirical studies and con-
ducted controlled outcome studies to determine how CT’s outcomes compared with
existing psychotherapy and pharmacotherapy treatments for depression. Beck’s
careful empirical approach was eventually adopted by colleagues around the world.
Evidence-supported CT approaches were developed for many disorders including
depression, panic disorder, social anxiety, phobias, posttraumatic stress disorder,
schizophrenia and other psychotic disorders, hypochondriasis, body dysmorphic
disorder, eating disorders, insomnia, anger issues, stress, chronic pain and fatigue,
and distress due to general medical problems such as cancer (Hofmann, Asnaani,
Vonk, Sawyer, & Fang, 2012; White & Freeman, 2000).
Beck’s original depression research revealed that depressed clients had a nega-
tive bias in their interpretation of certain life events, which resulted from active pro-
cesses of cognitive distortion (A. Beck, 1967). This led Beck to believe that a therapy
that helped depressed clients become aware of and change their negative thinking
could be helpful. Unlike Ellis, Beck did not assert that negative thoughts were the
sole cause of depression. Beck’s research indicated that depression could result from
LO4
opened the nonprofit Beck Institute for Cognitive
Therapy in suburban Philadelphia, and she is cur-
rently president of the institute. A premier training
organization, the institute is devoted to national and
international training in cognitive therapy through
workshop and supervision programs for students and
faculty, deployed and returning military families, and
health and mental health professionals at all levels.
Beck travels extensively in the United States
and abroad, teaching and disseminating cognitive
behavior therapy and assisting a wide variety of orga-
nizations in developing or strengthening their CT
programs. She writes a number of CT-oriented blogs
and edits “Cognitive Therapy Today,” an e-newsletter.
She is coauthor of the widely adopted self-report
scales, the Personality Belief Questionnaire and the
Beck Youth Inventories II, which screens children aged
7–18 for symptoms of depression, anxiety, disruptive
behavior, self-concept, and anger.
Beck is Clinical Associate Professor at the Uni-
versity of Pennsylvania and was instrumental in
founding the Academy of Cognitive Therapy, the
“home” organization for cognitive therapists world-
wide. She has written nearly a hundred articles and
chapters on a variety of CT topics and authored sev-
eral books on cognitive therapy, including Cognitive
Behavior Therapy: Basics and Beyond (2011a), Cognitive
Therapy for Challenging Problems: What to Do When the
Basics Don’t Work (2005), and the Cognitive Therapy
Worksheet Packet (2011b), as well as trade books with
a cognitive behavioral program for diet and main-
tenance. Judith Beck has been married for 34 years
and has three adult children, one of whom is a social
worker specializing in CT.
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282 C H A P T E R T E N
negative thinking, but it could also be precipitated by genetic, neurobiological, or
environmental changes. One of Beck’s early contributions was to recognize that
regardless of the cause of depression, once people became depressed, their thinking
reflected what Beck referred to as the negative cognitive triad: negative views of
the self (self-criticism),the world (pessimism), and the future (hopelessness). Beck
believed this negative cognitive triad maintained depression, even when negative
thoughts were not the original cause of an episode of depression (A. Beck 1967;
A. Beck, Rush, Shaw, & Emery, 1979).
Cognitive therapy (CT) has a number of similarities to both rational emotive
behavior therapy and behavior therapy. All of these therapies are active, directive, time-
limited, present-centered, problem-oriented, collaborative, structured, and empirical.
They include homework assignments and require clients to explicitly identify prob-
lems and the situations in which they occur (A. Beck & Weishaar, 2014). Similar to
REBT and unlike behavior therapy, CT is based on the theoretical rationale that the
way people feel and behave is influenced by how they perceive and place meaning on
their experience. Three theoretical assumptions of CT are (1) that people’s thought
processes are accessible to introspection, (2) that people’s beliefs have highly personal
meanings, and (3) that people can discover these meanings themselves rather than
being taught or having them interpreted by the therapist (Weishaar, 1993).
From the beginning Beck developed specific treatment protocols for each prob-
lem whereas Ellis might teach similar philosophical principles to people with anxi-
ety, depression, or anger. Despite these differences, therapists who practice behavior
therapy, REBT, and CT learn from each other, and considerable overlap exists in
methods used by all three schools of therapy in contemporary clinical practice. The
highest standard of practice today is to offer the best “evidence-based practice”
regardless of its origins, so a therapist might use behavioral methods to treat phobias
and cognitive methods to treat panic disorder because research has demonstrated
these methods to be most effective in treating these problems. Many therapists refer
to themselves as offering cognitive behavioral therapy regardless of whether their
original training was primarily in behavior therapy, REBT, or CT.
A Generic Cognitive Model
Reflecting on 50 years of research and the various applications of cognitive therapy,
Beck has proposed a generic cognitive model to describe principles that pertain
to all CT applications from depression and anxiety treatments to therapies for a
wide variety of other problems including psychosis and substance use (A. Beck &
Haigh, 2014). By linking psychological difficulties with adaptive human responses,
Beck believes the generic cognitive model “has the potential to be the only empiri-
cally supported general theory of psychopathology” (A. Beck & Haigh, 2014, p. 21).
The generic cognitive model provides a comprehensive framework for understand-
ing psychological distress, and some of its major principles are described here. Beck
encouraged others to design research to investigate the components of his model in
an effort to reach the best understanding possible of human cognition, behavior,
and emotion. Let’s look at some of the principles on which this model is based.
Psychological distress can be thought of as an exaggeration of normal adaptive human func-
tioning. When people are functioning well, they experience many different emotions
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C o g N I T I V E B E H A V I o R T H E R A P y 283
in response to life events and behave in ways that help them solve problems, achieve
goals, and protect themselves from harm. It is normal to sometimes withdraw from
relationships, avoid situations we don’t feel prepared to handle, or worry about
problems in the search of a solution. A psychological disorder begins when these
normal emotions and behaviors become disproportionate to life events in degree or
frequency. For example, when a person begins to worry most of the time, even about
situations that most people take in stride, that person is showing signs of general-
ized anxiety disorder.
Faulty information processing is a prime cause of exaggerations in adaptive emotional and
behavioral reactions. Our thinking is directly connected to our emotional reactions,
behaviors, and motivations. When we think about things in erroneous or distorted
ways, we experience exaggerated or distorted emotional and behavioral reactions as
well. Beck identifies several common cognitive distortions:
�� Arbitrary inferences are conclusions drawn without supporting evidence.
This includes “catastrophizing,” or thinking of the absolute worst sce-
nario and outcomes for most situations. You might begin your first job as
a counselor with the conviction that you will not be liked or valued. You
are convinced that you fooled your professors and somehow just managed
to get your degree, but now people will certainly see through you!
�� Selective abstraction consists of forming conclusions based on an isolated
detail of an event while ignoring other information. The significance
of the total context is missed. As a counselor, you might measure your
worth by your errors and weaknesses rather than by your successes.
�� Overgeneralization is a process of holding extreme beliefs on the basis
of a single incident and applying them inappropriately to dissimilar
events or settings. If you have difficulty working with one adolescent,
for example, you might conclude that you will not be effective counsel-
ing any adolescents. You might also conclude that you will not be effec-
tive working with any clients!
�� Magnification and minimization consist of perceiving a case or situation
in a greater or lesser light than it truly deserves. You might make this
cognitive error by assuming that even minor mistakes in counseling a
client could easily create a crisis for the individual and might result in
psychological damage.
�� Personalization is a tendency for individuals to relate external events to
themselves, even when there is no basis for making this connection. If
a client does not return for a second counseling session, you might be
absolutely convinced that this absence is due to your terrible perfor-
mance during the initial session. You might tell yourself, “This situ-
ation proves that I really let that client down, and now she may never
seek help again.”
�� Labeling and mislabeling involve portraying one’s identity on the basis
of imperfections and mistakes made in the past and allowing them
to define one’s true identity. If you are not able to live up to all of a
client’s expectations, you might say to yourself, “I’m totally worthless
and should turn my professional license in right away.”
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284 C H A P T E R T E N
�� Dichotomous thinking involves categorizing experiences in either-or extremes.
With such polarized thinking, you might view yourself as either being
the perfectly competent counselor (you always succeed with all clients)
or as a total flop if you are not fully competent (there is no room for any
mistakes).
Our beliefs play a major role in determining what type of psychological distress we will expe-
rience. Each emotional and behavioral disorder is accompanied by beliefs specific to
that problem. Consider two students who apply to college and are not accepted to
their first choice of school. One of the students becomes depressed, the other becomes
anxious. Depression is accompanied by negative thoughts about oneself (“I’ve failed,”
“Nothing will work out for me,” “I’ll never get into medical school”). Anxious thoughts
reflect overestimations of threat or danger (“Everyone will think less of me when they
find out I wasn’t admitted to that college”) and underestimations of one’s coping (“I
won’t know what to say to people about it”) and underestimation of resources (“These
other colleges won’t prepare me well enough for medical school”).
Central to cognitive therapy is the empirically supported observation that “changes in beliefs
lead to changes in behaviors and emotions” (A. Beck & Haigh, 2014, p.14). If the students
in the previous example can change the way they think about not being accepted to
their first choice school, their depression and anxiety are likely to be lessened. The
first student will undoubtedly feel less depressed once a more balanced view of the
rejection letter is adopted (“More good students apply than can be admitted. My
rejection does not mean I failed. I’m sure many students from my second choice
school go on to attend medical school.”). Similarly, the anxious student would ben-
efit from new beliefs as well (“I can tell others that I am disappointed that I did not
get into my first choice college. Some people might think less of me, but those who
really care about me will understand that not everyone gets their first choice and
they will be supportive.”).
If beliefs are not modified, clinical conditions are likely to reoccur. Even without counsel-
ing or a change in beliefs, people often recover from feelings of depression or anxiety
and return to their usual healthy functioning. However, these feelings may return in
times of future stress or disappointment if their basic beliefs have not changed. In
studies of the long-term effects of treatments for depression and anxiety disorders,
cognitive therapy and other types of CBT therapies have the lowest rates of relapse
(Hollon, Stewart, & Strunk, 2006). Many believe this is because these therapies lead
to enduring changes in beliefs.
Basic Principles of Cognitive Therapy
Cognitive therapy (CT) perceives psychological problems as an exaggeration
of adaptive responses resulting from commonplace cognitive distortions. Like REBT,
CT is an insight-focused therapy with a strong psychoeducational component that
emphasizes recognizing and changing unrealistic thoughts and maladaptive beliefs.
Cognitive therapy is highly collaborative and involves designing specific learning
experiences to help clients understand the links between their thoughts, behaviors,
emotions, physical responses, and situations (Greenberger & Padesky, 2016). The
goal of CT is to help clients learn practical skills that they can use to make changes in
their thoughts, behaviors, and emotions and how to sustain these changes over time.
LO5
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C o g N I T I V E B E H A V I o R T H E R A P y 285
In cognitive therapy, clients learn how to identify their dysfunctional thinking.
Once clients identify cognitive distortions, they are taught to examine and weigh
the evidence for and against them. This process of critically examining thoughts
involves empirically testing them by looking for evidence, actively engaging in a
Socratic dialogue with the therapist, carrying out homework assignments, doing
behavioral experiments, gathering data on assumptions made, and forming alterna-
tive interpretations (Dattilio, 2000a; Freeman & Dattilio, 1994; Tompkins, 2004,
2006). From the start of treatment, clients learn to employ specific problem-solving
and coping skills. Through a process of guided discovery, clients acquire insight
about the connection between their thinking and the ways they act and feel.
Cognitive therapy is focused on present problems, regardless of a client’s diag-
nosis. The past may be brought into therapy when the therapist considers it essen-
tial to understand how and when certain core dysfunctional beliefs originated and
how these ideas have a current impact on the client’s difficulties (Dattilio, 2002a).
The goals of this brief therapy include providing symptom relief, assisting clients in
resolving their most pressing problems, changing beliefs and behaviors that main-
tain problems, and teaching clients skills that serve as relapse prevention strategies.
Some Differences Between CT and REBT In both CT and REBT, reality testing
is highly organized. Clients come to realize on an experiential level that they have
misconstrued situations. Yet there are some important differences between these
two approaches, especially with respect to therapeutic methods and style.
REBT is often highly directive, persuasive, and confrontational, and the teach-
ing role of the therapist is emphasized. The therapist models rational thinking and
helps clients to identify and dispute irrational beliefs. In contrast, CT uses Socratic
dialogue, posing open-ended questions to clients with the aim of getting clients
to reflect on personal issues and arrive at their own conclusions. CT places more
emphasis on helping clients identify misconceptions for themselves rather than
being taught. Through this reflective questioning process, the cognitive therapist
collaborates with clients in testing the validity of their cognitions (a process called
collaborative empiricism). Therapeutic change is the result of clients reevaluating
faulty beliefs based on contradictory evidence that they have gathered.
There are also differences in how Ellis and Beck view faulty thinking. Through
a process of rational disputation, Ellis works to persuade clients that certain of
their beliefs are irrational and nonfunctional. Beck views his clients’ distorted
beliefs as being the result of cognitive errors rather than being driven solely by irra-
tional beliefs. Beck asks his clients to conduct behavioral experiments to test the
accuracy of their beliefs (Hollon & DiGiuseppe, 2011). Cognitive therapists view
dysfunctional beliefs as being problematic when they are a distortion of the whole
picture, or when they are too absolute, broad, and extreme (A. Beck & Weishaar,
2014). For Beck, people live by rules (underlying assumptions); they get into trouble
when they label, interpret, and evaluate by a set of rules that are unrealistic or when
they use the rules inappropriately or excessively. If clients decide they are living by
rules that are likely to lead to misery, the therapist asks clients to consider and test
out alternative rules. Although cognitive therapy operates within clients’ frame of
reference, the therapist continually asks clients to examine evidence for and against
their belief system.
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286 C H A P T E R T E N
The Client–Therapist Relationship
The therapeutic relationship is basic to the application of cognitive therapy.
Through his writings, it is clear that Beck believes effective therapists must com-
bine empathy and sensitivity with technical competence (A. Beck, 1987). The core
therapeutic conditions described by Rogers in his person-centered approach are
viewed by cognitive therapists as being necessary, but not sufficient, to produce opti-
mum therapeutic effect. A therapeutic alliance is a necessary first step in cognitive
therapy, especially in counseling difficult-to-reach clients. Without a working alli-
ance, techniques applied will not be effective (Dattilio & Hanna, 2012; Dienes et al.,
2011). Therapists must have a cognitive conceptualization of cases, be creative and
active, be able to engage clients through a process of Socratic questioning, and be
knowledgeable and skilled in the use of cognitive and behavioral strategies aimed
at guiding clients in significant self-discoveries that will lead to change (A. Beck &
Weishaar, 2014).
Cognitive therapists are continuously active and deliberately interactive with
clients, helping clients frame their conclusions in the form of testable hypotheses.
The cognitive therapist functions as a catalyst and a guide who helps clients under-
stand how their beliefs and attitudes influence the way they feel and act. Clients
are expected to identify the distortions in their thinking, summarize important
points in the session, and collaboratively devise homework assignments that they
agree to carry out. Cognitive therapists emphasize the client’s role in self-discovery.
The assumption is that lasting changes in the client’s thinking and behavior will be
most likely to occur with the client’s initiative, understanding, awareness, and effort
(A. Beck & Weishaar, 2014; J. Beck, 2005, 2011a; J. Beck & Butler, 2005).
Cognitive therapists identify specific, measurable goals and move directly
into the areas that are causing the most difficulty for clients (Dienes et al., 2011).
Typically, a therapist will educate clients about the nature and course of their
problem, about the process of cognitive therapy, and how thoughts influence
their emotions and behaviors.. One way of educating clients is through biblio-
therapy, in which clients complete readings that support and expand their under-
standing of cognitive therapy principles and skills. These readings are assigned
as an adjunct to therapy and are designed to enhance the therapeutic process by
providing an educational focus (Dattilio & Freeman, 2007; Jacobs, 2008). Self-
help books such as Mind Over Mood (Greenberger & Padesky, 2016) also provide
an educational focus.
Homework is often used as a part of cognitive therapy because practicing cogni-
tive behavioral skills in real life facilitates more rapid and enduring gains (Dienes
et al., 2011). The purpose of homework is not merely to teach clients new skills but
also to enable them to test their beliefs and to try out different behaviors in daily-
life situations. Homework is generally presented to clients as an experiment that
serves to continue work on issues addressed in a therapy session (Dattilio, 2002b).
Cognitive therapists realize that clients are more likely to complete homework if it is
tailored to their needs, if they participate in designing the homework, if they begin
the homework in the therapy session, and if they talk about potential problems in
implementing the homework (J. Beck, 2005). Tompkins (2004, 2006) points out that
there are clear advantages to the therapist and the client working in a collaborative
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C o g N I T I V E B E H A V I o R T H E R A P y 287
manner in negotiating mutually agreeable homework tasks. One indicator of a
good therapeutic alliance is whether homework is done and done well (Kazantzis,
Dattilio, Cummins, & Clayton, 2014).
Applications of Cognitive Therapy
Cognitive therapy initially gained recognition as an approach to treating depres-
sion, but extensive research has been devoted to the study and treatment of many
other psychiatric disorders. The popularity of cognitive therapy is due in part
to the “strong empirical support for its theoretical framework and to the large
number of outcome studies with clinical populations” (A. Beck & Weishaar, 2014,
p. 260). Hundreds of research studies have confirmed the theoretical underpin-
nings of CT, and hundreds of outcome trials have established its efficacy for a
wide range of psychiatric disorders, psychological problems, and medical condi-
tions with psychological components (Hofmann et al., 2012).
Cognitive therapy has been successfully used to treat depression, each of the anxiety
disorders, cannabis dependence, hypochondriasis, body dysmorphic disorder, eating
disorders, anger, schizophrenia, insomnia, and chronic pain (Chambless & Peterman,
2006; Dattilio & Kendall, 2007; Hofmann et al., 2012; Riskind, 2006); suicidal behavior,
borderline personality disorders, narcissistic personality disorders, and schizophrenic
disorders (Dattilio & Freeman, 2007); personality disorders (Pretzer & Beck, 2006); sub-
stance abuse (Newman, 2006); medical illness (Dattilio & Castaldo, 2001); crisis inter-
vention (Dattilio & Freeman, 2007); couples and families therapy (Dattilio, 1993, 1998,
2001, 2005, 2010; Dattilio & Padesky, 1990; Epstein, 2006); and child abusers, divorce
counseling, skills training, and stress management (Dattilio, 1998; Granvold, 1994;
Reinecke, Dattilio, & Freeman, 2002). With children and adolescents, CT has been
shown to be effective in the treatment of depression and anxiety disorders and more
effective than medications for these problems. Clearly, cognitive therapy programs have
been designed for all ages and for a variety of client populations.
Moreover, the effects of CT for depression and anxiety disorders seem to be
more enduring that the effects of other treatments, with the exception of behavior
therapy, which sometimes matches CT in duration of positive outcome. People who
get better using CT are less likely to relapse than those who improve with medica-
tion or most other psychotherapy approaches (Hollon et al., 2006). For an excellent
resource on the clinical applications of cognitive therapy to a wide range of disorders
and populations, see Contemporary Cognitive Therapy (Leahy, 2006a).
Applying Cognitive Techniques Beck and Weishaar (2014) describe both cognitive
and behavioral methods that are part of the overall strategies used by cognitive
therapists. Cognitive methods focus on identifying and examining a client’s beliefs,
exploring the origins of these beliefs, and modifying them if the evidence does not
support these beliefs. Examples of behavioral techniques typically used by cognitive
therapists include activity scheduling, behavioral experiments, skills training, role
playing, behavioral rehearsal, and exposure therapy. Regardless of the nature of the
specific problem, the cognitive therapist is mainly interested in applying procedures
that will assist individuals in making alternative interpretations of events in their
daily living and behaving in ways that move them closer to their goals and values.
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288 C H A P T E R T E N
Treatment Approaches The length and course of cognitive therapy varies greatly
and is determined by the therapy protocols used for specific diagnoses. For example,
cognitive therapy for depression generally lasts 16 to 20 sessions and begins with
behavioral activation. Activity has an antidepressant effect, especially when the
client engages in a mix of pleasurable, accomplished, and anti-avoidance activities.
Clients rate their moods in relation to the activities they do throughout the day,
and these observations are used as guides to find activities that provide a mood
boost in subsequent weeks. As depression begins to lift, the therapist introduces
additional skills such as thought records, which help clients identify negative
automatic thoughts and test them. When evidence does not support the automatic
thought, clients learn to generate alternative explanations that are less depressing.
When evidence does support the problematic thought, clients are helped to create
an action plan to solve the problem rather than ruminating on it (Greenberger
& Padesky, 2016). Before the end of treatment, underlying assumptions that put
clients at risk for relapse are examined such as perfectionistic assumptions (“If I
make a mistake, then I am worthless”). These assumptions are tested with behavioral
experiments. For example, a perfectionistic client may intentionally make a mistake
doing a particular task and evaluate whether there is still some worth and value to
the outcome.
In contrast, cognitive therapy for panic disorder generally lasts only 6 to
12 sessions and targets catastrophic beliefs about internal physical and mental
sensations (Clark et al., 1999). Clients are helped to identify the sensations that
trigger a panic attack and the catastrophic beliefs about these sensations. For
example, a client may think, “My heart is racing (sensation). That means I am hav-
ing a heart attack (catastrophic belief).” The therapist helps the client generate an
alternative hypothesis to explain these feared sensations. For example, “A racing
heart is not dangerous. It can be caused by exercise, anxiety, caffeine, and many
other things. The heart is a muscle, and doctors recommend that you regularly
raise your heart rate in exercise to keep it healthy.” The therapist then guides the
client to conduct a series of experiments in a session in which the client creates
the sensation and weighs evidence in support of the catastrophic and alterna-
tive hypotheses. Once the client begins to believe the alternative hypotheses in
these experiments, which later are also done outside of therapy, panic attacks are
reduced or disappear.
Application to Family Therapy The cognitive behavioral approach focuses on
cognitions, emotions, and behavior as they exert a mutual influence on one another
within family relationships to cause dysfunction. Cognitive theory (A. Beck, 1976;
A. Beck & Haigh, 2014) emphasizes schema, elsewhere defined as core beliefs, as
key aspect of the therapeutic process. Therapists help families restructure distorted
beliefs (or schema) in order to change dysfunctional behaviors. Some CT therapists
place a strong emphasis on examining cognitions among individual family members
as well as on what may be termed the “family schemata” (Dattilio, 1993, 1998, 2001,
2010). These jointly held beliefs about the family have formed as a result of years of
interaction among family members. These schemata are influenced by the parents’
family of origin and have a major impact on how each individual thinks, feels, and
behaves in the family system (Dattilio, 2001, 2005, 2010).
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C o g N I T I V E B E H A V I o R T H E R A P y 289
For a concrete illustration of how Dr. Dattilio applies cognitive principles and
works with family schemata, see his cognitive behavioral approach with Ruth in Case
Approach to Counseling and Psychotherapy (Corey, 2013, chap. 8). For a discussion of
myths and misconceptions of cognitive behavior family therapy, see Dattilio (2001);
for a concise presentation on the cognitive behavioral model of family therapy, see
Dattilio (2010). Also, for an expanded treatment of applications of cognitive behav-
ioral approaches to working with couples and families, see Dattilio (1998).
Christine Padesky and Kathleen Mooney’s Strengths-Based
Cognitive Behavioral Therapy
Introduction
Strengths-based cognitive behavior therapy (SB-CBT) is a variant of Aaron Beck’s cog-
nitive therapy developed by Christine Padesky and her colleague Kathleen Mooney
(Padesky & Mooney, 2012). All the principles and evidence-based treatments devel-
oped by Aaron Beck and his colleagues are incorporated in strengths-based CBT.
CHRISTINE A. PADESKY (b. 1953) was
born and raised in the Midwest. As an
undergraduate science major at Yale
University, she took a psychology course
and became fascinated with this field,
which offered a link between her scien-
tific and social change interests. While
a PhD student in clinical psychology at
the University of California, Los Ange-
les, Padesky and her graduate research
adviser published an article on gender
differences in depression symptoms
that caught the attention of Aaron
Beck. Beck and Padesky met and became friends,
and he was her mentor throughout her career (see
Padesky, 2004). In the 1980s she and Beck taught
more than 20 workshops together in the United
States and abroad.
At Beck’s invitation, in 1983 Padesky opened
one of the first Centers for Cognitive Therapy in the
western United States (now located in Huntington
Beach, California). She partnered in this venture with
Kathleen Mooney, a creative CBT therapist dedicated
to innovation and therapist education. Together they
trained and hired staff for their clinic, which became
a leading international training center. Padesky and
Mooney developed many innovations in the practice
of cognitive therapy including the use of constructive
questions, the importance of identifying
client imagery and metaphors for change,
and an emphasis on client strengths. These
innovations eventually formed the founda-
tion of their therapy approach, known as
strengths-based CBT (SB-CBT).
In 1995, Greenberger and Padesky
(2016) first published Mind Over Mood:
Change How You Feel by Changing the Way You
Think, which became a popular self-help
sensation. With sales of more than one
million copies worldwide in 23 languages,
Padesky’s dream of teaching people skills
to improve their own moods so they did not need to
rely on experts was realized.
Padesky lectures and teaches workshops in the
United States and abroad. She is a consultant to thera-
pists and clinics worldwide and participates in a num-
ber of research programs evaluating strengths-based
CBT. She was a featured presenter at the Evolution
of Psychotherapy conference in 2013 and the Brief
Therapy conference in 2014. In addition to Mind Over
Mood, she has written four professional books and
numerous articles and book chapters on a variety of
CBT topics. She produces top-rated video demonstra-
tions of CBT in action and has an extensive catalog
of audio training programs for mental health profes-
sionals and graduate students in mental health fields.
Christine A. Padesky
Ch
ris
tin
e
Pa
de
sk
y
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290 C H A P T E R T E N
As the name implies, one central addition of SB-CBT is an emphasis on identification
and integration of client strengths at each phase of therapy. The main idea of sb-cbt
is that active incorporation of client strengths encourages clients to engage more fully
in therapy and often provides avenues for change that otherwise would be missed.
SB-CBT expands previous models of CBT to include methods that help people
develop positive qualities. Their ideas developed in parallel with positive psychology,
a research field that investigates happiness, resilience, altruism, and a host of positive
emotions and behaviors (Lopez & Snyder, 2011). In a keynote address at an interna-
tional conference, Padesky (2007) proposed that the next frontier in psychotherapy
would be development of methods to enhance human experience and strengths
instead of working solely to alleviate suffering. SB-CBT is a step in that direction.
Basic Principles of Strengths-Based CBT
Like cognitive therapy, SB-CBT is empirically based. This means that (1) thera-
pists should be knowledgeable about evidence-based approaches pertaining to client
issues discussed in therapy, (2) clients are asked to make observations and describe
the details of their life experiences so what is developed in therapy is based in the real
data of clients’ lives, and (3) therapists and clients collaborate in testing beliefs and
experimenting with new behaviors to see if they help achieve desired goals.
Strengths are integrated into each phase of treatment in SB-CBT beginning with
the intake interview. After reasons for seeking therapy are described and explored,
the SB-CBT therapist expresses an interest in positive aspects of the client’s life:
“Thank you for telling me about the reasons you came to therapy. Even though this
is a tough time for you, I wonder if there are some things that are going well in your
life or that bring you happiness, even now. If you are willing to tell me about some of
those things, it will help me know you more as a whole person.”
In Collaborative Case Conceptualization: Working Effectively With Clients in CBT,
Kuyken, Padesky, and Dudley (2009) show how positive interests and strengths
identified in early therapy sessions can provide a wealth of information to help ther-
apist and client collaboratively integrate strengths into case conceptualization and
treatment. For example, clients often discover that they use more resilient strategies
when they encounter obstacles in areas of positive interest than they do in problem
areas of their life. These strategies can be added to plans to deal positively with prob-
lem areas. A depressed client learning to be more active to boost mood will have an
easier time engaging in activities that are part of a hobby or positive pastime than
participating in activities that hold little interest for the client.
SB-CBT therapists help clients develop and construct new positive ways of inter-
acting in the world. The SB-CBT model for building and strengthening personal
resilience can be used on its own or integrated with another evidenced-based CBT
treatment for a diagnostic disorder (Padesky & Mooney, 2012). For clients with
chronic difficulties that have proven resistant to change, SB-CBT proposes that it is
often easier to construct an entirely new way of doing things than to problem solve
or modify a chronic way of doing things. When clients do not respond to standard
treatments, SB-CBT therapists help clients co-create a “NEW Paradigm,” which is
their vision of how they would like to be and how they would like the difficult area
of their life to be.
LO6
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C o g N I T I V E B E H A V I o R T H E R A P y 291
The Client–Therapist Relationship
As with Beck’s cognitive therapy, SB-CBT therapists are collaborative, active, here-
and-now focused, and client-centered. SB-CBT therapists are encouraging allies of
their clients and need to be genuine, caring, and willing to engage with clients as
full human beings in both struggles and successes. SB-CBT therapists do not take
an “expert” stance but instead serve as curious assistants or guides to their clients’
own discovery and growth.
SB-CBT practitioners ask clients for imagery and metaphors to describe their expe-
riences, both positive and negative. More than words, imagery and metaphors capture
and integrate the emotional, cognitive, physiological, and behavioral aspects of expe-
rience. In addition to deconstructing beliefs and problems, SB-CBT emphasizes the
constructive use of Socratic questioning. The SB-CBT therapist asks constructive ques-
tions such as, “How would you like to be? “How would you like this part of your life
or relationships to be?” When clients are stuck in recurring patterns, SB-CBT teaches
them that we do things “for good reasons” and shows clients how even destructive
behaviors (such as cutting oneself when distressed) are done for self-protective reasons
and as attempts to cope (“If I cut myself, then I will feel some emotional relief.”).
Applications of Strengths-Based CBT
Three current applications for SB-CBT are as (1) an add-on for classic CBT, (2) a
four-step model to build resilience and other positive qualities, and (3) the NEW
Paradigm for chronic difficulties and personality disorders. SB-CBT operates as an
add-on to classic CBT when clients come to therapy with goals to reduce problematic
moods (depression, anxiety, anger), behaviors (eating disorders, substance misuse) or
other difficulties (psychoses, hypochondriasis) for which there are well-established
and effective CBT protocols. In those cases, SB-CBT therapists help clients identify
their strengths and rely on these whenever helpful to guide therapy choices.
The four-step model to build resilience provides a template for building positive
qualities (Padesky & Mooney, 2012). Their four steps are (1) search, (2) construct,
(3) apply, and (4) practice. Padesky and Mooney point out that there are usually
just a few common pathways to a psychological disorder, but there are thousands
of pathways to resilience. Rather than teach clients particular ways to be resilient,
Padesky and Mooney suggest that therapists inquire about activities in clients’ lives
that are going well and that clients do on a regular basis. These everyday activities
clients are motivated to do are areas of strength. This search for strengths is the first
step in their model.
The second step is to discover what obstacles clients encounter while doing
these activities and how they manage these obstacles. A central idea is that everybody
encounters obstacles in any frequently practiced activity but we manage obstacles
without even realizing that is what we are doing when we enjoy the activity. For
example, Joseph loves to play video games. He uses a variety of strategies to manage
obstacles as they occur within the game and from external causes (such as loss of
power to his electronic device). Joseph’s strategies include problem solving, seeking
help from friends, reminding himself that “I’ve been stuck before and always found
a way through,” and music to keep up his energy. These strategies are written down
as his Personal Model of Resilience (PMR).
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292 C H A P T E R T E N
The third step involves the therapist helping Joseph creatively consider how he
can apply his PMR to remain resilient in a more problematic area of his life, such as
dating. Joseph makes a plan for how to use these strategies to help him meet people
he would like to date, ask them out, and solve various dating difficulties than have
proven challenging for him in the past.
The fourth stage involves Joseph conducting a series of dating experiments
while he practices maintaining a focus on resilience. A key to this stage of the ther-
apy is that Joseph sets a goal to “be resilient in the face of challenges,” not to succeed
at dating. Because his goal is to “stay resilient” he has a better chance of experiencing
his dates in a positive way. Even if he and his date don’t get along, he can feel good
about staying resilient. This can help Joseph feel motivated no matter what hap-
pens. Over time, his resilience will be expressed both in persistence (problem solving,
getting help from friends) and in acceptance that not every date will turn out as he
would like (but he can enjoy the music anyway).
The same principles can be used to build other positive qualities such as altru-
ism, creativity, and courage. The key is to find everyday areas of the person’s life
where these qualities are already in evidence. For example, even a self-centered
person may be very kind and concerned for a pet or certain friends. From these
everyday experiences, the person can be helped to build a Personal Model of X (for
example, altruism) and then consider how to apply and practice this positive qual-
ity in other life settings.
The final application of SB-CBT is the NEW Paradigm for chronic issues and
personality disorders. This approach is more comprehensive and requires clients to
vividly construct new ways to feel, think, and behave in their life. The four steps
of this model are (1) Conceptualize the OLD System of operating and help clients
understand they do things “for good reasons,” (2) construct NEW systems of how
clients would like to be, (3) strengthen the NEW using behavioral experiments to try
on NEW ways of being and edit them as needed, and (4) relapse management. Thera-
pists need significant training to practice the NEW Paradigm because it is essential
that the therapist stay alert to identify when the OLD System interferes with client
learning. The therapist must be able to help the client learn from every experience
and process this learning through the NEW System, not the OLD.
DONALD MEICHENBAUM (b. 1940)
was born in New York City (the Bronx)
and learned early to be “street smart”
and to be on the lookout for high-risk
situations. He attended City College of
New York and received his PhD in clin-
ical psychology from the University
of Illinois. At the University of Water-
loo in Ontario, Canada, he conducted
research on the development of cogni-
tive behavior therapy (CBT). He is one
of the founders of cognitive behavior
therapy, and in a survey of clinicians
he was voted one of the most influen-
tial therapists in the 20th century. He
is the recipient of a Lifetime Achieve-
ment Award from the Clinical Division
of the American Psychological Associa-
tion for his work on suicide prevention.
In 1995 Meichenbaum retired from the
University of Waterloo to become the
research director of the Melissa Insti-
tute for Violence Prevention, which is
designed to “give science away” in order
to reduce violence and to treat victims
of violence.
Donald
Meichenbaum
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ity
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ol
og
y
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C o g N I T I V E B E H A V I o R T H E R A P y 293
Donald Meichenbaum’s Cognitive Behavior Modification
Introduction
Donald Meichenbaum’s cognitive behavior modification (CBM) focuses on chang-
ing the client’s self-talk. According to Meichenbaum (1977), self-statements affect a
person’s behavior in much the same way as statements made by another person. A
basic premise of CBM is that clients, as a prerequisite to behavior change, must notice
how they think, feel, and behave and the impact they have on others. For change to
occur, clients need to interrupt the scripted nature of their behavior so that they can
evaluate their behavior in various situations (Meichenbaum, 1993, 2007).
This approach shares with REBT and Beck’s cognitive therapy the assumption
that distressing emotions are often the result of maladaptive thoughts. REBT is
more direct and confrontational in uncovering and disputing irrational thoughts,
whereas Meichenbaum’s self-instructional training focuses more on helping clients
become aware of their self-talk and the stories they tell about themselves. Both REBT
and CT focus on changing thinking processes, but Meichenbaum suggests that it
may be easier and more effective to change our behavior rather than our thinking.
Furthermore, our emotions and thinking are two sides of the same coin: the way
we feel can affect our way of thinking, just as how we think can influence how we
feel. The therapeutic process consists of teaching clients to make self-statements
and training clients to modify the instructions they give to themselves so that they
can cope more effectively with the problems they encounter. Cognitive restructur-
ing plays a central role in Meichenbaum’s (1977, 1993) self-instructional training.
He describes cognitive structure as the organizing aspect of thinking, which moni-
tors and directs the choice of thoughts through an “executive processor” that “holds
the blueprints of thinking” that determines when to continue, interrupt, or change
thinking. Together, therapist and client practice the self-instructions and the desir-
able behaviors in role-play situations that simulate problem situations in the client’s
daily life. The emphasis is on acquiring practical coping skills for problematic situ-
ations such as impulsive and aggressive behavior, anxiety in social situations, fear of
taking tests, eating problems, and fear of public speaking.
Meichenbaum attributes the origin of CBT to his
mother, who had a knack for telling stories about her
daily activities that were peppered with her thoughts,
feelings, and a running commentary. This childhood
experience contributed to Meichenbaum’s psycho-
therapeutic approach of constructivist narrative
therapy, in which clients tell their stories and describe
what they did to “survive and cope.” Meichenbaum’s
recent work with returning service members using
iPod technology to bolster resilience is modeled on
this approach. When therapy is successful, Meichen-
baum ensures that clients take credit for the changes
they have achieved. As he observes, “I am at my
therapeutic best when the clients I see are one step
ahead of me offering the observations or suggestions
that I would otherwise offer” (Donald Meichenbaum,
personal communication, October 21, 2010).
Meichenbaum has published extensively, includ-
ing Cognitive Behavior Therapy: An Integrative Approach
(1977), Stress Inoculation Training (1985), Treatment of
Individuals With Anger-Control Problems and Aggressive
Behaviors (2002), and Roadmap to Resilience (2012).
He has lectured in every state and in all provinces in
Canada as well as internationally. He was a featured
presenter at the Evolution of Psychotherapy confer-
ence in 2013 and the Brief Therapy conference in 2014.
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294 C H A P T E R T E N
How Behavior Changes
Meichenbaum (1977) proposes that “behavior change occurs through a
sequence of mediating processes involving the interaction of inner speech, cogni-
tive structures, and behaviors and their resultant outcomes” (p. 218). He describes
a three-phase process of change in which those three aspects are interwoven and
believes that focusing on only one aspect will probably prove insufficient.
Phase 1: Self-observation. Clients learning how to observe their own behavior.
When clients begin therapy, their internal dialogue is characterized by nega-
tive self-statements and imagery. A critical factor is their willingness and
ability to listen to themselves. This process involves an increased sensitivity
to their thoughts, feelings, actions, physiological reactions, and ways of
reacting to others. If depressed clients hope to make constructive changes,
for example, they must first realize that they are not “victims” of negative
thoughts and feelings. Rather, they are actually contributing to their depres-
sion through the things they tell themselves. Although self-observation is
necessary if change is to occur, it is not sufficient for change.
Phase 2: Starting a new internal dialogue. As a result of the early client–
therapist contacts, clients learn to notice their maladaptive behaviors,
and they begin to see opportunities for adaptive behavioral alternatives. If
clients hope to change what they are telling themselves, they must initiate
a new behavioral chain, one that is incompatible with their maladaptive
behaviors. Clients learn that psychological distress is a function of the
interdependence of cognitions, emotions, behaviors, and resultant conse-
quences. In therapy, clients learn to change their internal dialogue, which
serves as a guide to new behavior.
Phase 3: Learning new skills. Clients learn to interrupt the downward spiral
of thinking, feeling, and behaving, and the therapist teaches clients more
adaptive ways of coping using the resources they bring to therapy. Clients
learn more effective coping skills, which are practiced in real-life situa-
tions. As they behave differently in situations, they typically get different
reactions from others. The stability of what they learn is greatly influenced
by what they say to themselves about their newly acquired behavior and its
consequences.
Stress Inoculation Training
A particular application of a coping skills program is teaching clients stress
management techniques by way of a strategy known as stress inoculation training
(SIT). Using cognitive techniques, Meichenbaum (1985, 2007, 2008) has developed
stress inoculation procedures that are a psychological and behavioral analog to
immunization on a biological level. Individuals are given opportunities to deal with
relatively mild stress stimuli in successful ways, and they gradually develop a toler-
ance for stronger stimuli. This training is based on the assumption that we can
affect our ability to cope with stress by modifying our beliefs and self-statements
about our performance in stressful situations. Meichenbaum’s stress inoculation
LO7
LO8
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C o g N I T I V E B E H A V I o R T H E R A P y 295
training is concerned with more than merely teaching people specific coping skills.
His program is designed to prepare clients for intervention and motivate them to
change, and it deals with issues such as resistance and relapse.
Stress inoculation training is a combination of information giving, Socratic
discovery-oriented inquiry, cognitive restructuring, problem solving, relaxation
training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforcement,
and modifying environmental situations (Meichenbaum, 2008). Collaborative goals
are set that nurture hope, direct-action skills, and acceptance-based coping skills.
These coping skills are designed to be applied to both present problems and future
difficulties. Clients are assisted in generalizing what they have learned so they can
use these skills in daily living, and relapse prevention strategies are taught. Meichen-
baum (2008) describes stress inoculation training as a complex, multifaceted, cogni-
tive behavioral intervention that is both a preventive and a treatment approach.
Clients can acquire more effective strategies in dealing with stressful situations
by learning how to modify their cognitive “set,” or core beliefs. The following proce-
dures are designed to teach these coping skills:
�� Expose clients to anxiety-provoking situations by means of role playing
and imagery
�� Require clients to evaluate their anxiety level
�� Teach clients to become aware of the anxiety-provoking cognitions they
experience in stressful situations
�� Help clients examine these thoughts by reevaluating their
self-statements
�� Have clients note the level of anxiety following this reevaluation
The Phases of Stress Inoculation Training Meichenbaum (2007, 2008) has designed
a three-stage model for stress inoculation training: (1) the conceptual-educational
phase, (2) the skills acquisition and consolidation phase, and (3) the application
and follow-through phase.
During the conceptual-educational phase, the primary focus is on creating a ther-
apeutic alliance with clients. This is done by helping clients gain a better under-
standing of the nature of stress and reconceptualizing it in social-interactive terms.
Initially, clients are provided with a conceptual framework in simple terms designed
to educate them about ways of responding to a variety of stressful situations. They
learn about the role cognitions and emotions play in creating and maintaining
stress through didactic presentations, by curious questioning, and by a process of
guided self-discovery. A collaborative relationship is created during this early phase,
and together they rethink the stress concerns clients bring to understand the nature
of the problem.
Clients often begin treatment feeling that they are victims of external circum-
stances, thoughts, feelings, and behaviors over which they have no control. As a way
to understand the subjective world of clients, the therapist generally elicits stories
that clients tell themselves. Training includes teaching clients to become aware of
their own role in creating their stress and their life stories. They acquire this aware-
ness by systematically observing the statements they make internally as well as by
monitoring the maladaptive behaviors that flow from this inner dialogue. Such
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296 C H A P T E R T E N
self-monitoring continues throughout all the phases. As is true in cognitive ther-
apy, clients typically keep an open-ended diary in which they systematically monitor
and record their specific thoughts, feelings, and behaviors. In teaching these coping
skills, therapists strive to be flexible in their use of techniques and to be sensitive to
the individual, cultural, and situational circumstances of their clients.
During the skills acquisition and consolidation phase, the focus is on giving clients a
variety of behavioral and cognitive coping skills to apply to stressful situations. This
phase involves direct actions, such as gathering information about their fears, learning
specifically what situations bring about stress, arranging for ways to lessen the stress
by doing something different, and learning methods of physical and psychological
relaxation. The training involves cognitive coping; clients are taught that adaptive and
maladaptive behaviors are linked to their inner dialogue. Through this training, cli-
ents acquire and rehearse a new set of self-statements. Meichenbaum (1986) provides
some examples of coping statements that are rehearsed in this phase of SIT:
�� “How can I prepare for a stressor?” (“What do I have to do? Can I
develop a plan to deal with the stress?”)
�� “How can I confront and deal with what is stressing me?” (“What are
some ways I can handle a stressor? How can I meet this challenge?”)
�� “How can I cope with feeling overwhelmed?” (“What can I do right
now? How can I keep my fears in check?”)
�� “How can I make reinforcing self-statements?” (“How can I give myself
credit?”)
Clients also are exposed to various behavioral interventions, such as relaxation
training, social skills training, time-management instruction, and self-instructional
training. They are helped to make lifestyle changes by reevaluating priorities,
developing support systems, and taking direct action to alter stressful situations.
Through teaching, demonstration, and guided practice, clients learn the skills of
progressive relaxation and practice them regularly to decrease arousal due to stress.
During the application and follow-through phase, the focus is on carefully arranging
for transfer and maintenance of change from the therapeutic situation to everyday
life. Clients practice their new self-statements and apply their new skills to everyday
life. To consolidate the lessons learned in the training sessions, clients participate in
a variety of activities, including imagery and behavior rehearsal, role playing, model-
ing, and graded in-vivo exposure. Once clients have become proficient in cognitive
and behavioral coping skills, they practice behavioral assignments, which become
increasingly demanding. They are asked to write down the homework assignments
they are willing to complete. The outcomes of these assignments are carefully
checked at subsequent meetings, and if clients do not follow through with them,
the therapist and the client collaboratively consider the reasons for the failure.
relapse prevention, which consists of procedures for dealing with the inevi-
table setbacks clients are likely to experience as they apply what they are learning to
daily life, is taught at this stage (Marlatt & Donovan, 2005). Clients learn to view any
lapses that occur as “learning opportunities” rather than as “catastrophic failures.”
Clients explore a variety of possible high-risk, stressful situations that they may reex-
perience. In a collaborative fashion with the therapist, and with other clients in a
group, clients rehearse and practice applying the skills they have learned to maintain
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C o g N I T I V E B E H A V I o R T H E R A P y 297
the gains they have made. Follow-up and booster sessions typically take place at 3-,
6-, and 12-month periods as an incentive for clients to continue practicing and refin-
ing their coping skills. SIT can be considered part of an ongoing stress management
program that extends the benefits of training into the future.
Stress inoculation training has potentially useful applications for a wide variety
of problems and clients and for both remediation and prevention. Clinical appli-
cations of SIT are individually tailored to specific target populations and include
anger control, pain control, anxiety management, assertion training, improving
creative thinking, treating depression, dealing with health problems, and preparing
for surgery. Stress inoculation training has been employed with medical patients
and with psychiatric patients. Meichenbaum (2007) contends that the flexibility of
the SIT format has contributed to its robust effectiveness. SIT has been successfully
used with children, adolescents, and adults who have anger problems, anxiety dis-
orders, phobias, social incompetence, addictions, alcoholism, sexual dysfunctions,
social withdrawal, or posttraumatic stress disorder (PTSD), including use with vet-
erans who experience combat-related PTSD (Meichenbaum, 1993, 1994a, 1994b,
2007, 2008, 2012).
A Cognitive Narrative Approach to Cognitive Behavior Therapy
Meichenbaum (2015) has embraced a cognitive narrative perspective, which focuses
on the plots, characters, and themes in the stories people tell about themselves
and others regarding significant events in their lives. Therapists elicit stories from
their clients that are explored in the therapy process. This approach begins with the
assumption that there are multiple realities. One of the therapeutic tasks is to help
clients appreciate how they construct their realities and how they author their own
stories (see Chapter 13). Meichenbaum claims that we are all “story tellers” and that
we should be aware of the stories we tell ourselves and others. For example, some
clients might see themselves as “prisoners of the past” or as “stubborn victims.”
These phrases are not idle metaphors; they are the organizing schemas that color
the ways individuals view themselves, their world, and their future. Therapists help
clients appreciate how they construct reality and examine the implications and con-
clusions clients draw from their stories. Telling the “rest of the story”—what they
did to survive and cope—bolsters clients’ strengths and helps them develop resilient-
engendering behaviors. In this way, clients can move from being “stubborn victims”
to becoming “tenacious survivors” and perhaps “impressive thrivers.” Meichenbaum
(2012) works in a collaborative fashion with clients to develop the coping skills neces-
sary to achieve these treatment goals. He uses a Socratic discovery-oriented approach
and the art of questioning to assist clients in reaching their goals.
Meichenbaum (1997) uses these questions to evaluate the outcomes of therapy:
�� Are clients now able to tell a new story about themselves and the
world?
�� Do clients now use more positive metaphors to describe themselves?
�� Are clients able to predict high-risk situations and employ coping skills
in dealing with emerging problems?
�� Are clients able to take credit for the changes they have been able to
bring about?
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298 C H A P T E R T E N
In successful therapy clients develop their own voices, take pride in what they have
accomplished, and take ownership of the changes they are bringing about. In short,
clients become their own therapists and take the therapist’s voice with them.
Cognitive Behavior Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
Cognitive behavioral approaches have several strength in working with indi-
viduals from diverse cultural, ethnic, and racial backgrounds. If therapists under-
stand the core values of their culturally diverse clients, they can help clients explore
these values and gain a full awareness of their conflicting feelings. Then the client
and the therapist can work together to modify selected beliefs and practices. Cogni-
tive behavior therapy tends to be culturally sensitive because it uses the individual’s
belief system, or worldview, as part of the method of self-exploration.
Because counselors with a cognitive behavioral orientation function as teach-
ers, clients are actively involved in learning skills to deal with the problems of living.
In speaking with colleagues who work with culturally diverse populations, I have
learned that their clients tend to appreciate the emphasis on cognition and action,
as well as the stress on relationship issues. The collaborative approach of CBT offers
clients a structured therapy program, yet the therapist still makes every effort to
enlist clients’ active cooperation and participation. According to Spiegler (2013),
because of its basic nature and the way CBT is practiced, it is inherently suited to
treating diverse clients. Some of the factors that Spiegler identifies that makes CBT
diversity effective include individualized treatment, focus on the external environ-
ment, active nature, emphasis on learning, reliance on empirical evidence, concern
with present behavior, and brevity. A strength of CBT is integrating assessment of
client beliefs, emotional responses, and behavioral choices throughout therapy,
which communicates respect for clients’ viewpoints regarding their progress.
Hays (2009) asserts there is an “almost perfect fit” between cognitive behav-
ior therapy and multicultural therapy because these perspectives share common
assumptions that make integration possible. Aspects that contribute to an integra-
tive framework include the following:
�� Interventions are tailored to the unique needs and strengths of the
individual.
�� Clients are empowered by learning specific skills they can apply in daily
life (CBT) and by the emphasis on cultural influences that contribute to
clients’ uniqueness (multicultural therapy).
�� Inner resources and strengths of clients are activated to bring about change.
�� Clients make changes that minimize stressors, increase personal
strengths and supports, and establish skills for dealing more effectively
with their physical and social (cultural) environments.
Shortcomings From a Diversity Perspective
Exploring values and core beliefs plays an important role in all of the cog-
nitive behavioral approaches, and it is crucial for therapists to have some
LO9
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C o g N I T I V E B E H A V I o R T H E R A P y 299
understanding of the cultural background of clients and to be sensitive to their
struggles. REBT therapists would do well to use caution in their choice of lan-
guage and expression when confronting clients about their beliefs and behav-
iors. REBT suggests that the therapist’s job is to help clients critically examine
long-standing cultural values that result in dysfunctional emotions or behav-
iors, but a potential limitation of REBT is its negative view of dependency. Many
cultures view interdependence as necessary to good mental health. Clients with
long-cherished cultural values pertaining to interdependence may not respond
favorably to forceful methods of persuasion toward independence. Skillful
REBT practitioners carefully monitor their manner, style, and choice of words
and communicate whenever possible in language that is congruent with the cli-
ent’s culture.
Hays (2009) suggests that therapists avoid challenging the core cultural
beliefs of clients unless the client is clearly open to this. By emphasizing col-
laboration over confrontation, as the cognitive behavioral approaches do, the
therapist can avoid seeming to be disrespectful. Hays recommends drawing on
the client’s culturally related strengths in developing helpful ways of thinking to
replace unhelpful cognitions. For example, consider an Asian American client,
Sung, from a culture that stresses values such as doing one’s best, cooperation,
interdependence, and working hard. Sung may feel that she is bringing shame to
her family if she is going through a divorce, and she may feel guilt if she perceives
that she is not living up to the expectations and standards set for her by her fam-
ily and her community. Sung can be helped to consider how her cultural values of
cooperation and interdependence may enable her family to support her during a
difficult divorce. The rules for Sung are likely to be different than are the rules for
a male member of her culture. The counselor could assist Sung in understanding
and exploring how both her gender and her culture are factors to consider in her
situation. If Sung is confronted too quickly on living by the expectations or rules
of others, the results are likely to be counterproductive. Sung might even leave
counseling if she feels that she is not being understood.
The emphasis of CBT on assertiveness, independence, verbal ability, ratio-
nality, cognition, and behavioral change may limit its use in cultures that value
subtle communication over assertiveness, interdependence over personal inde-
pendence, listening and observing over talking, and acceptance over behavior
change (Hays, 2009). In CBT the focus is on the present, which can result in
the therapist failing to recognize the role of the past in a client’s development.
Cognitive behavioral assessments involve the investigation of a client’s personal
history. If the therapist is unaware of a client’s cultural beliefs, which are rooted
in the past, the therapist may have difficulty interpreting the client’s personal
experiences accurately.
Another limitation of CBT from a multicultural perspective involves its indi-
vidualistic orientation. An inexperienced therapist may overemphasize cognitive
restructuring to the neglect of environmental interventions. Hays (2009) points out
that these potential limitations do not preclude the integration of CBT and multi-
cultural counseling. Instead, being aware of these limitations “presents opportuni-
ties for rethinking, refining, adapting and increasing the relevance and effectiveness
of psychotherapy” (p. 356).
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300 C H A P T E R T E N
F rom a cognitive behavioral perspective, I want Stan to critically evaluate and modify his self-
defeating beliefs, which will likely result in Stan ac-
quiring more effective behavior. As his therapist, I am
both goal oriented and problem focused. From the
initial session, I ask Stan to identify his problems and
formulate specific goals and help him reconceptualize
his problems in a way that will increase his chances of
finding solutions.
I follow a clear structure for every session. The
basic procedural sequence includes (1) preparing
him by providing a cognitive rationale for treatment
and demystifying treatment; (2) encouraging him to
monitor the thoughts that accompany his distress;
(3) implementing behavioral and cognitive tech-
niques; (4) assisting him in identifying and examin-
ing some basic beliefs and ideas; (5) teaching him
ways to examine his beliefs and assumptions by test-
ing them in the real world; and (6) teaching him basic
coping skills that will enable him to avoid relapsing
into old patterns.
As a part of the structure of the therapy sessions,
I ask Stan for a brief review of the week, elicit feedback
from the previous session, review homework assign-
ments, collaboratively create an agenda for the session,
discuss topics on the agenda, and set new homework
for the week. I encourage Stan to perform personal ex-
periments and practice coping skills in daily life.
Stan tells me that he would like to work on his
fear of women and would hope to feel far less intimi-
dated by them. He reports that he feels threatened by
most women, but especially by women he perceives
as powerful. In working with Stan’s fears, I proceed
with four steps: educating him about his self-talk;
having him monitor and evaluate his faulty beliefs;
using cognitive and behavioral interventions; and
collaboratively designing homework with Stan that
will give him opportunities to practice new behaviors
in daily life.
First, I educate him about the importance of ex-
amining his automatic thoughts, his self-talk, and
the many “shoulds,” “oughts,” and “musts” he has ac-
cepted without questioning. Working with Stan as a
collaborative partner in his therapy, I guide him in dis-
covering some basic thoughts that influence what he
tells himself and how he feels and acts. Here are some
of his beliefs:
�� “I always have to be strong, tough, and perfect.”
�� “I’m not a man if I show any signs of weakness.”
�� “If everyone didn’t love me and approve of me,
things would be catastrophic.”
�� “If a woman rejected me, I really would be reduced
to a ‘nothing.’”
�� “If I fail, I am then a failure as a person.”
�� “I’m apologetic for my existence because I don’t
feel equal to others.”
Second, I assist Stan in monitoring and evaluat-
ing the ways in which he keeps telling himself these
self-defeating ideas. I assist him in clarifying specific
problems and learning how to critically evaluate his
thinking.
Therapist: You’re not your father. I wonder why you
continue telling yourself that you’re just like him.
Where is the evidence that your parents were right
in their assessment of you? What is the evidence
they were not right in their assessment of you? You
say you’re such a failure and that you feel inferior.
Do your present activities support this? If you were
not so hard on yourself, how might your life be
different?
Third, once Stan more fully understands the
nature of his cognitive distortions and his self-
defeating beliefs, I draw on a variety of cognitive and
behavioral techniques to help Stan learns to identify,
evaluate, and respond to his beliefs. I rely heavily
on cognitive techniques such as Socratic questioning,
guided discovery, and cognitive restructuring to assist
Stan in examining the evidence that seems to sup-
port or contradict his core beliefs. I work with Stan so
he will view his basic beliefs and automatic thinking
as hypotheses to be tested. In a way, he will become
a personal scientist by checking out the validity of
many of the conclusions and basic assumptions that
contribute to his personal difficulties. By the use of
Cognitive Behavior Therapy Applied to the Case of Stan
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C o g N I T I V E B E H A V I o R T H E R A P y 301
guided discovery, Stan learns to evaluate the valid-
ity and functionality of his beliefs and conclusions.
Stan can also profit from cognitive restructuring,
which would entail observing his own behavior in
various situations. For example, during the week he
can take a particular situation that is problematic
for him and pay attention to his automatic thoughts
and internal dialogue: What is he telling himself as
he approaches a difficult situation? As he learns to
attend to his thoughts and behaviors, he may begin
to see that what he tells himself has as much impact
as others’ statements about him. He also sees the
connections between his thinking and his behavioral
problems. With this awareness he is in an ideal place
to begin to learn a new, more functional internal
dialogue.
Fourth, I work collaboratively with him in creat-
ing specific homework assignments to help him deal
with his fears. It is expected that Stan will learn new
coping skills, which he can practice first in session and
then in daily life situations. It is not enough for him to
merely say new things to himself; Stan needs to apply
his new cognitive and behavioral coping skills in vari-
ous daily situations. At one point, for instance, I ask
Stan to explore his fears of powerful women and his
reasons for continuing to tell himself: “They expect
me to be strong and perfect. If I’m not careful, they’ll
dominate me.” His homework includes approaching a
woman for a date. If he succeeds in getting the date,
he can think about his catastrophic expectations of
what might happen. What would be so terrible if she
did not like him or if she refused the date? Stan tells
himself over and over that he must be approved of and
that if any woman rebuffs him the consequences are
more than he can bear. With practice, he learns to label
distortions and is able to automatically identify his
negative thoughts and monitor his cognitive patterns.
Through a variety of cognitive and behavioral strate-
gies, he is able to acquire new information, change his
basic beliefs, and implement new and more effective
behavior.
Questions for Reflection
�� My therapeutic style is characterized as an integra-
tive form of cognitive behavioral therapy. I borrow
concepts and techniques from the approaches of
Ellis, Beck, and Meichenbaum. In your work with
Stan, what specific concepts would you borrow
from these approaches? What cognitive behavioral
techniques would you use? What possible advan-
tages do you see, if any, in applying an integrative
cognitive behavioral approach in your work with
Stan? Would there be any benefits in adding ideas
from Padesky and Mooney’s strengths-based
CBT?
�� What are some things you would most want to
teach Stan about how cognitive behavior therapy
works? How would you explain to him the thera-
peutic alliance and the collaborative therapeutic
relationship?
�� What are some of Stan’s most prominent faulty
beliefs that get in the way of his living fully? What
cognitive and behavioral techniques might you use
in helping him examine his beliefs?
�� Stan lives by many “shoulds” and “oughts.” His
automatic thoughts seem to impede him from get-
ting what he wants. What techniques would you
use to encourage guided discovery on his part?
�� What are some homework assignments that
would be useful for Stan to carry out? How would
you collaboratively design homework with Stan?
How would you encourage him to develop action
plans to test the validity of his thinking and his
conclusions?
Visit CengageBrain.com or watch the DVD for
Theory and Practice of Counseling and Psychotherapy:
The Case of Stan and Lecturettes, Session 8 (cogni-
tive behavior therapy), for a demonstration of my
approach to counseling Stan from this perspective.
This session focuses on exploring some of Stan’s
faulty beliefs through the use of role-reversal and
cognitive restructuring techniques.
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302 C H A P T E R T E N
Gwen comes in, takes a seat, and begins telling me about the upcoming office retreat that she has to
attend. Gwen wants to be more accepted and connect-
ed but has gotten into a pattern of isolating herself
and using excuses not to socialize with others.
Gwen: I am dreading spending eight hours out in the
country with a bunch of people I don’t really care
to spent time with in the office! I know it’s going to
be horrible!
Therapist: Stop for a moment and pay attention to
your thoughts around being with your colleagues.
What evidence do you have to support your predic-
tion about attending the retreat? [Sensing a cognitive
distortion]
Gwen: I never interact with my coworkers, and I can’t
imagine that the retreat will be interesting. I feel
anxious when I am around my coworkers. I do not
feel that I am a part of their group. I feel judged
and scrutinized by them.
Gwen’s faulty assumptions and cognitive distor-
tions fuel her anxiety. I want to help Gwen recognize
these old irrational thoughts and learn that these
thoughts have caused her anxiety. “Awfulizing” the
upcoming social event leads to more anxiety and trig-
gers her desire to isolate herself. If Gwen can become
more self-aware, she will be able to actively dispute her
faulty beliefs.
Therapist: You are telling yourself that you will have a
horrible time at the retreat. You think your cowork-
ers will judge you. What evidence do you have that
they are judging you? Do you have any evidence that
suggests one or several of your coworkers are not
judging you? Imagine that you are holding a picture
of the retreat and how you fit in at work. The frame
is old and dusty. What would happen if you put a
new frame on the picture? Can you reframe your
thoughts about going to the retreat and interacting
with your coworkers in a more positive way?
Gwen: Well, I don’t have to say it will be horrible. I
guess that thought makes me dread it. I truthfully
don’t know how it will go at all. Maybe I can tell
myself to show up without judgment for a change
and just see what happens. I get caught up in nega-
tive thinking sometimes.
Therapist: When you hear negative words in your
mind or say them, allow yourself to cancel those
thoughts. Dispute the negative statement, and
replace it with a statement that supports how you
want to feel and think about yourself. Tell me some
of the cognitive distortions that keep you stuck in
anxiety or negative feelings.
Gwen: I say to myself that the people at work are
waiting for me to make a mistake, that I am differ-
ent, and that they don’t want to socialize with me.
Actually, I haven’t really tried to get to know them.
Therapist: What can you do differently in the work-
place to foster relationships with your coworkers
that might serve to reduce your anxiety?
Gwen: I guess I could say hello to my coworkers in-
stead of walking through the office ignoring them.
I really do want to create positive relationships in
the office and not feel like an outsider.
Therapist: And how will you respond to those nag-
ging thoughts that everyone is against you?
Gwen: I am beginning to realize that there is really no
evidence to support feeling that I am being judged
and scrutinized by my coworkers. Maybe I am quiet
because I am afraid they will reject me, and so I
reject them first.
Therapist: Let’s agree on some homework for this
week. When you are feeling judged and scrutinized,
see if you can counter the assumptions you are
making by looking at the facts.
Gwen: Maybe I could make a list of my assumptions
and some of the negative thoughts that result from
them. Then I could try to list some facts that coun-
ter those negative thoughts.
Therapist: I am glad you are willing to try to find
some facts to work with. I think this will help you
to be less anxious.
Cognitive Behavior Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing in a CBT framework and applying this model to Gwen.
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Summary and Evaluation
Summary
REBT has evolved into a comprehensive and integrative approach that emphasizes
thinking, assessing, deciding, doing, and compassion. This approach is based on
the premise of the interconnectedness of thinking, feeling, and behaving. Therapy
can begin with clients’ problematic behaviors and emotions, and clients can learn
to dispute the thoughts that directly create them. To block any self-defeating beliefs
that are reinforced by a process of self-indoctrination, REBT therapists employ active
and directive techniques such as teaching, suggestion, persuasion, and homework
assignments, and they encourage clients to substitute a rational belief system for an
irrational one. Therapists demonstrate how and why dysfunctional beliefs lead to
negative emotional and behavioral results. They teach clients how to dispute self-
defeating beliefs and behaviors that might occur in the future. REBT emphasizes the
benefit of taking action—doing something about the insights one gains in therapy.
Change comes about mainly by practicing new behaviors that replace old and inef-
fective ones. Unconditional self-acceptance, unconditional other-acceptance, and
unconditional life-acceptance are strongly encouraged. Rational emotive behavior
therapists are typically eclectic in selecting therapeutic strategies. They have the lati-
tude to develop their own personal style and to exercise creativity; they are not bound
by fixed techniques for particular problems.
Cognitive therapists also practice from an integrative stance, using many meth-
ods to help clients learn to identify links between thoughts, emotions, behaviors,
physiology, and situations. Some defining characteristics of cognitive therapy are
that the client is active and works as a partner with the therapist; the therapist is
active and directive; the therapy is structured and psychoeducational; an agenda
provides focus for each session; and therapy is time limited (Freeman & Freeman,
2016). The working alliance is given special importance in cognitive therapy as a
way of forming a collaborative partnership. Although rapport in the client–therapist
relationship is viewed as helpful by Beck, it is not considered sufficient for therapy
C o g N I T I V E B E H A V I o R T H E R A P y 303
Gwen: And I will try to be more friendly at work.
Therapist: Isolating yourself doesn’t seem to be work-
ing, so let’s see how you feel when you talk with
your coworkers.
I give Gwen a journal to record her homework ex-
periments and how doing a new behavior affects her
anxiety level. I encourage her to develop awareness of
the automatic thoughts that occur to her so she can
become more adept at catching and disputing them.
In our next session, we discuss her homework and
evaluate the response it has had on her level of anxiety
in the workplace.
Questions for Reflection
�� What role, if any, does Gwen play in her experi-
ences of isolation?
�� How does the therapist intervene to assist Gwen in
looking for evidence for her negative thinking?
�� How would you encourage Gwen to complete her
homework assignment?
�� How would you respond if you knew that Gwen
was being subjected to racism and rejection in the
office? How would CBT help her in that case?
�� What additional CBT technique might you use if
you were counseling Gwen?
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304 C H A P T E R T E N
success. In cognitive therapy, it is presumed that clients are helped by the skillful
use of a range of cognitive and behavioral interventions and by therapists engag-
ing clients’ willingness to perform homework assignments between sessions. Ther-
apists are expected to be able to conceptualize client problems in ways that link
personal client experiences to the evidence-based treatments that are most likely to
be successful.
All of the cognitive behavioral approaches stress the importance of links
between cognitive processes, emotions, and behavior. It is assumed that how people
feel and what they actually do is largely influenced by their subjective assessment and
interpretation of situations. Because this appraisal of life situations is influenced
by beliefs, attitudes, assumptions, and internal dialogue, such cognitions become a
major focus of therapy.
Contributions of the Cognitive Behavioral Approaches
Most of the therapies discussed in this book can be considered “cognitive”
in a general sense because they have the aim of changing clients’ subjective views
of themselves and the world. The cognitive behavioral approaches have developed
systematic and sophisticated forms of psychotherapy that focus on testing assump-
tions and beliefs and teaching clients the coping skills needed to deal with their
problems. A basic principle of CBT is emotional and behavioral changes can be
achieved by changing cognitions, just as cognitive change can be altered by actions
and emotions (Freeman & Freeman, 2016).
Ellis’s REBT and Beck’s CT represent the most systematic applications of cog-
nitive behavior therapy. Both REBT and CT are based on a wide range of cognitive
behavioral techniques and follow a defined plan of action; they can often be relatively
brief and structured treatments in keeping with the spirit of maximizing effectiveness
and efficiency, cost effectiveness, and evidence-based practice (Hollon & DiGiuseppe,
2011). The psychoeducational aspect of CBT and REBT is a clear strength that can be
applied to many clinical problems and used effectively in many settings with diverse
client populations (A. Ellis & Ellis, 2011). The evidence basis in support of CBT thera-
pies often makes them the “gold standard” by which therapy effectiveness is judged.
Ellis’s REBT One of the strengths of REBT is the focus on teaching clients ways to
carry on their own therapy without the direct intervention of a therapist. I particularly
like the emphasis that REBT puts on supplementary and psychoeducational
approaches such as listening to tapes, reading self-help books, keeping a record
of what they are doing and thinking, and carrying out homework assignments. In
this way clients can further the process of change in themselves without becoming
excessively dependent on a therapist.
Beck’s Cognitive Therapy Beck’s key concepts share similarities with REBT
but differ in being empirically rather than philosophically derived, the processes
by which therapy proceeds, and the formulation and treatment for different
disorders. Beck made pioneering efforts in the treatment of anxiety, phobias, and
depression. Beck demonstrated that a structured therapy that is present centered
and problem oriented can be very effective in treating depression and anxiety in a
LO10
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C o g N I T I V E B E H A V I o R T H E R A P y 305
relatively short time. Today, empirically validated treatments for both anxiety and
depression have revolutionized therapeutic practice; research has demonstrated the
efficacy of cognitive therapy for a variety of problems (Leahy, 2002; Scher, Segal, &
Ingram, 2006; Hofmann et al., 2012). Beck developed specific cognitive procedures
to help depressive clients evaluate their assumptions and beliefs and to create a new
cognitive perspective that can lead to optimism and changed behavior. Research
demonstrates that the effects of cognitive therapy on depression and hopelessness
are usually maintained for at least one year after treatment. Cognitive therapy has
been applied to a wide range of clinical populations that Beck did not originally
believe were appropriate for this model, including treatment for posttraumatic
stress disorder, schizophrenia, delusional disorders, bipolar disorder, and various
personality disorders (Hofmann et al., 2012). The credibility of the cognitive model
grows out of the fact that many of its propositions have been empirically tested.
Padesky and Mooney’s Strengths-Based CBT Beck’s CT has been further expanded
with Padesky and Mooney’s strengths-based CBT approach. In addition to
incorporating strengths at each phase of treatment, SB-CBT has successfully
incorporated a wide range of modalities including imagery, metaphor, stories,
and kinesthetic body experiences into the broad repertoire of CBT interventions.
SB-CBT also provides models that extend CBT from evidence-based treatment of
client problems to evidence-based models for developing positive qualities and
client strengths. Instead of focusing solely on testing existing beliefs, SB-CBT offers
systematic methods for helping clients construct new beliefs and behaviors that
help realize their goals of “how they would like to be.”
Meichenbaum’s Cognitive Behavior Modification Meichenbaum’s work in self-
instruction and stress inoculation training has been applied successfully to a variety
of client populations and specific problems. Of special note is his contribution
to understanding how stress is largely self-induced through inner dialogue.
Meichenbaum’s integration of the cognitive narrative perspective is a key strength
of his therapy style. He is able to combine elements of the postmodern interest in
stories clients tell with assisting clients in changing their cognitions, feelings, and
behaviors by drawing on a cognitive behavioral conceptual framework.
A contribution of all of the cognitive behavioral approaches is the emphasis on
putting newly acquired insights into action. Homework assignments are well suited to
enabling clients to practice new behaviors and assisting them in the process of learn-
ing more effective coping skills. It is important that collaboratively created homework
be a natural outgrowth of what is taking place in the therapy session. Ellis’s REBT,
Beck’s cognitive therapy, Padesky and Mooney’s strengths-based CBT, and Meichen-
baum’s stress inoculation training all place special emphasis on practicing new skills
both in therapy and in daily life, and homework is a key part of the learning process.
Clients learn how to generalize coping skills to various problem situations and acquire
relapse prevention strategies to ensure that their gains are consolidated.
A major contribution made by Ellis, the Becks, Padesky and Mooney, and
Meichenbaum is the demystification of the therapy process. The cognitive behavioral
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306 C H A P T E R T E N
approaches are based on an educational model that stresses a working alliance
between therapist and client. The models encourage self-help, provide for continu-
ous feedback from the client on how well treatment strategies are working, and pro-
vide a structure and direction to the therapy process that allows for evaluation of
outcomes. Clients are active, informed, and responsible for the direction of therapy
because they are partners in the enterprise.
Limitations and Criticisms of the Cognitive Behavioral Approaches
Some critics have charged that the cognitive behavioral approaches focus
only limited attention on the role of emotions in treatment. These therapies
were originally developed to help people already experiencing extreme emotional
arousal, and this perception may be an artifact of that fact. When clients are severely
depressed or highly anxious, it is beneficial to focus less directly on these emotions
per se and more on the balancing roles of belief and behavior. When CBT therapists
work with clients who keep emotion at arms’ length, they use imagery, role play,
and emotional expression to elicit emotion and bring it into therapy. Although CBT
therapists may not talk about emotion as frequently as some other therapies, CBT is
almost always dealing directly with emotion and its consequences. Some potential
limitations of the various CBT approaches follow.
Ellis’s REBT I question the REBT assumption that exploring the past is ineffective
in helping clients change faulty thinking and behavior. From my perspective,
exploring past childhood experiences can have a great deal of therapeutic power
if the discussion is connected to present functioning. In fact, Albert Ellis would
(and Debbie Joffe Ellis continues to) listen to past childhood experiences in the
initial session, or during early sessions. These stories can be valuable as sources of
irrational beliefs still held by the client in the here and now. Attention would then
very quickly move to exploring, disputing, and replacing these beliefs.
Another potential limitation involves the misuse of the therapist’s power by
imposing ideas of what constitutes rational thinking. Due to the active and direc-
tive nature of this approach, it is particularly important for practitioners to avoid
imposing their own philosophy of life on their clients. The skillful REBT therapist
clarifies the REBT definitions of rational versus irrational thoughts and healthy neg-
ative emotions versus unhealthy negative emotions (A. Ellis & Ellis, 2011).
Some clients may have trouble with a confrontational style of REBT, especially
if a strong therapeutic alliance has not been established. It is well to underscore
that REBT can be effective when practiced in a style different from Ellis’s. Albert
Ellis often expressed that therapists do not need to emulate his style to effectively
incorporate REBT into their own repertoire of interventions. Debbie Joffe Ellis,
who continues to teach and write about the “Ellis” REBT approach, enthusiastically
encourages therapists to adhere to REBT tenets and principles in their own authen-
tic manner and style (D. Ellis, 2014).
Beck’s Cognitive Therapy Cognitive therapy has been criticized for focusing
too much on the power of positive thinking; being too superficial and simplistic;
denying the importance of the client’s past; being too technique oriented; failing to
LO11
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C o g N I T I V E B E H A V I o R T H E R A P y 307
use the therapeutic relationship; working only on eliminating symptoms, but failing
to explore the underlying causes of difficulties; ignoring the role of unconscious
factors; and neglecting the role of feelings (Freeman & Dattilio, 1992; Weishaar, 1993).
Although the cognitive therapist is straightforward and looks for simple rather
than complex solutions, this does not imply that the practice of cognitive therapy
is simple. Cognitive therapists do not pursue positive thinking but rather thinking
based on actual experiences. Cognitive therapists do not believe the unconscious is
difficult to access. With direct and guided questioning, clients can identify assump-
tions and beliefs that exist below awareness and also link these beliefs to behavioral
patterns and emotional reactions. They also recognize that clients’ current problems
are often a product of earlier life experiences, and they may explore with clients the
ways their past is presently influencing them.
Padesky and Mooney’s Strengths-Based CBT The biggest criticism of strengths-
based CBT is that the evidence base supporting the approach is still in its infancy. Some
CBT therapists question whether the addition of client strengths adds anything to
CBT’s effectiveness. Studies currently under way in Europe and the United Kingdom
are testing this hypothesis, especially to see whether a strengths and resilience focus
increases the enduring effects of therapy. Further research is necessary to examine
whether construction of new beliefs and behaviors is more effective than examining
current beliefs and behaviors in the treatment of chronic problems.
Meichenbaum’s Cognitive Behavior Modification Meichenbaum is very charismatic
in his workshop presentations. Much of the success of his approach may be based on
his level of caring and his creativity in implementing CBT interventions. Practitioners
without his wit, energy, personal flair, and direct therapeutic style may not get the
same results even though they follow his treatment protocol. This emphasizes the
importance for each therapist to develop his or her own unique therapeutic style.
A potential limitation of any of the cognitive behavioral approaches is the thera-
pist’s level of personal development, training, knowledge, skill, perceptiveness, and
ability to establish a therapeutic alliance. Although this is true of all therapeutic
approaches, it is especially true for CBT practitioners because they tend to be active,
highly structured, offer clients useful information, and teach life skills. Who the ther-
apist is as a person is as important as knowledge and skills. Therapists teach their
clients through what they model. Debbie Joffe Ellis (2014) encourages practitioners
to strive to be mindful, to think about their thinking, and to do their best to practice
what they preach. In so doing, they can be healthy models for their clients and others
and experience greater authenticity and satisfaction in their own lives as well.
Self-Reflection and Discussion Questions
1. In most CBT models, the therapist functions in many ways as a
teacher. How does a psychoeducational model fit with your way of
practicing counseling?
2. Cognitive behavioral practitioners use a brief, active, directive, collab-
orative, present-focused, didactic, psychoeducational model of therapy
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308 C H A P T E R T E N
that relies on empirical validation of its concepts and techniques. What
potential advantages do you see of this focus? Any disadvantages?
3. Ellis, Beck, Padesky, and Meichenbaum are all in the cognitive behav-
ioral camp, yet they all have distinctive approaches to counseling.
Which of these approaches are you most drawn to and why?
4. CBT provides for use of a wide range of techniques. What techniques
might you apply to yourself? What techniques are you likely to incor-
porate in your work with clients?
5. The cognitive behavioral therapies are among the most popular with
today’s practitioners. What do you think accounts for the increased
interest in CBT?
Where to Go From Here
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes, I work with Ruth
from a cognitive behavioral perspective in a number of therapy sessions. In Sessions
6, 7, and 8, I demonstrate my way of working with Ruth from a cognitive, emotive,
and behavioral focus. See also Session 9 (“Integrative Perspective”), which illustrates
the interactive nature of working with Ruth on thinking, feeling, and doing levels.
Other Resources
DVDs relevant to this chapter offered by the American Psychological Association
from their Systems of Psychotherapy Video Series include the following:
Beck, J. (2005). Cognitive Therapy
Ellis, D. J. (2014). Rational Emotive Behavior Therapy
Meichenbaum, D. (2007). Cognitive Behavioral Therapy With Donald
Meichenbaum
Vernon, A. (2010). Rational Emotive Behavior Therapy Over Time
Dobson, K. S. (2010). Cognitive Therapy Over Time
Persons, J. (2006). Cognitive-Behavior Therapy
Dobson, K. S. (2008). Cognitive-Behavioral Therapy for Perfectionism
Over Time
Dobson, K. S. (2011). Cognitive-Behavioral Therapy Strategies
Audio recordings of workshops and videos relevant to this chapter that illus-
trate CBT protocols and methods in practice are also offered by Padesky at www
. padesky.com:
Padesky, C. A. (1993). Cognitive Therapy for Panic Disorder
Padesky, C. A. (1996).Guided Discovery Using Socratic Dialogue
Padesky, C. A. (1996). Testing Automatic Thoughts With Thought Records
Padesky, C. A. (1997). Collaborative Case Conceptualization
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C o g N I T I V E B E H A V I o R T H E R A P y 309
Padesky, C. A. (2003). Constructing NEW Core Beliefs
Padesky, C. A. (2004). Constructing NEW Underlying Assumptions & Behavioral
Experiments
Padesky, C. A. (2008). CBT for Social Anxiety
Padesky, C. A. (2015). A Four-Step Approach to Building Resilience
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on cognitive behavior therapy. New video and edi-
torial content is made available monthly. DVDs relevant to this chapter are available
at www.psychotherapy.net.
For information about the work of Albert Ellis, and current presentations and
REBT trainings, contact:
Debbie Joffe Ellis
www.debbiejoffeellis.com
Additional websites of interest on REBT:
www.ellisrebt.com
www.rebtnetwork.org
The International Journal of Cognitive Therapy provides information on theory,
practice, and research in cognitive behavior therapy. For information about the jour-
nal, contact:
International Journal of Cognitive Therapy
www.guilford.com
Padesky and Mooney’s Center for Cognitive Therapy, Huntington Beach, Califor-
nia, has separate websites for mental health professionals and for the public. At
the website for mental health professionals, you can download pdf files of many
of Padesky and Mooney’s writings, visit Padesky’s blog, and find recommendations
for cognitive therapy books for both professionals and the public, audio and video
training programs, workshops, consultations, and other cognitive therapy resources
and information. The website for the public offers information about finding a CBT
therapist, CBT articles of interest to the public, and links to the publishers of Mind
Over Mood in more than 22 languages.
Center for Cognitive Therapy
www.padesky.com (for mental health professionals)
www.MindOverMood.com (for the public)
For more information about CBT workshops, supervision, a CBT blog, and
newsletter, contact:
Beck Institute for Cognitive Behavior Therapy
www.beckinstitute.org
The “home” organization for cognitive therapists worldwide is the Academy
of Cognitive Therapy, which Aaron T. Beck and Judith S. Beck were instrumen-
tal in founding. Links to certified cognitive therapists worldwide as well as links
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310 C H A P T E R T E N
to research and professional books of interest to therapists are available at this
website:
Academy of Cognitive Therapy
www.academyct.org
Donald Meichenbaum is research director of the Melissa Institute for Violence
Prevention, a nonprofit organization designed to “give science away” in order to
reduce violence and to treat victims of violence. The institute is dedicated to the
study and prevention of violence through education, community service, research
support, and consultation.
Melissa Institute for Violence Prevention
www.melissainstitute.org
Recommended Supplementary Readings
Rational Emotive Behavior Therapy (A. Ellis & Ellis,
2011) is a concise basic primer on REBT and is a
good resource for updated information about the
approach.
Albert Ellis Revisited (Carlson & Knaus, 2014) con-
tains some of Ellis’s most influential writings on a
variety of subjects. This edited book includes com-
mentaries by contributors for each of Ellis’s articles.
Cognitive Therapy: Basics and Beyond (J. Beck, 2011a) is
a main text in cognitive therapy that presents a com-
prehensive overview of the approach. An earlier edi-
tion of this book was translated into 20 languages.
Cognitive Therapy for Challenging Problems (J. Beck,
2005) is a comprehensive account of cognitive ther-
apy procedures applied to clients who present a mul-
tiplicity of difficult behaviors. It covers the nuts and
bolts of cognitive therapy with various populations
and cites important research on cognitive therapy
since its inception.
Mind Over Mood: Change How You Feel by Chang-
ing the Way You Think (Greenberger & Padesky,
2016) provides step-by-step worksheets to identify
moods, solve problems, and test thoughts related to
depression, anxiety, anger, guilt, and shame. This is
a popular self-help workbook and a valuable tool
for therapists and clients learning cognitive therapy
skills.
Clinician’s Guide to Mind Over Mood (Padesky &
Greenberger, 1995) shows therapists how to inte-
grate Mind Over Mood in therapy and use cognitive
therapy treatment protocols for specific diagnoses.
This succinct overview of cognitive therapy has
troubleshooting guides, reviews cultural issues, and
offers guidelines for individual, couples, and group
therapy.
Collaborative Case Conceptualization: Working Effec-
tively With Clients in CBT (Kuyken, Padesky, &
Dudley, 2009) shows therapists how to collabora-
tively construct case conceptualizations with cli-
ents in session and use these to guide treatment
planning. This book emphasizes using client
strengths to build client resilience while targeting
distress.
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311
11Choice Theory/ Reality Therapy
1. Identify the key figures associated
with reality therapy.
2. Describe how choice theory is the
theoretical underpinning of reality
therapy.
3. Understand the concept and clinical
implications of total behavior.
4. Examine the basic assumptions,
unique characteristics, and goals
of reality therapy.
5. Understand the role of therapist
involvement in creating a
counseling environment that is
conducive to success.
6. Explain how the WDEP model is
applied to practice.
7. Describe the application of reality
therapy to group counseling.
8. Identify the strengths and
shortcomings of reality therapy
in a multicultural context.
9. Examine the contributions and
limitations of the reality therapy
approach.
L e a r n i n g O b j e c t i v e s
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312 C H A P T E R E L E V E N
ROBERT E. WUBBOLDING (b. 1936), born and raised
in Cincinnati, Ohio, is the youngest of six children.
He received his doctorate in counseling from the Uni-
versity of Cincinnati, is a member of several profes-
sional organizations, and has licenses as a counselor
and as a psychologist. He taught high school history,
worked as a high school and elementary school coun-
selor, and served as a consultant to drug and alcohol
abuse programs of the U.S. Army and Air Force. Wub-
bolding began a career in the Catholic priesthood but
later “left the clergy freely and honorably.” He is mar-
ried to Sandra Trifilio, a former French teacher, who
WILLIAM GLASSER (1925—2013) was
educated at Case Western Reserve Uni-
versity in Cleveland, Ohio. Initially a
chemical engineer, he turned to psychol-
ogy (MA, Clinical Psychology, 1948) and
then to psychiatry, attending medical
school (MD, 1953) with the intention of
becoming a psychiatrist. By 1957 he had
completed his psychiatric training at
the Veterans Administration and UCLA
in Los Angeles and in 1961 was board
certified in psychiatry. Glasser was mar-
ried to Naomi for 47 years, and she was
very involved with the William Glasser Institute until
her death in 1992. In 1995 Glasser married Carleen,
who is an instructor at the institute and coauthor of
several of his books.
Very early Glasser rejected the Freudian model,
partly due to his observation of psychoanalytically
trained therapists who did not seem to be imple-
menting Freudian principles. Rather, they tended to
hold people responsible for their behavior. Early in
his career, Glasser was a psychiatrist at the Ventura
School, a prison and school for girls operated by the
California Youth Authority. He became convinced
that his psychoanalytic training was of limited util-
ity in counseling these young people. From these
observations, Glasser thought it best to talk to the
sane part of clients, not their disturbed side. Glasser
was also influenced by G. L. Harrington, a psychia-
trist and mentor. Harrington believed in getting his
patients involved in projects in the real world, and by
the end of his residency Glasser began to put together
ideas that would later be known as reality therapy.
In 1962 Glasser began to present public lectures
on “reality psychiatry,” but few psychiatrists were
in the audience. Most of those attending were edu-
cators, social workers, counselors, and correctional
workers, so Glasser changed the name of his system
to “reality therapy,” which became the title of his
groundbreaking book published in 1965.
Educators found the principles of real-
ity therapy helpful, and he was asked to
apply it to the classroom and the school
as an organization. As a result of this
experience, he wrote Schools Without Fail-
ure in 1968, which had a major impact on
the administration of schools, the train-
ing of teachers, and the way learning is
conducted in schools. Glasser took the
position that schools needed to be struc-
tured in ways to help students achieve
a success identity as opposed to a failure
identity. He advocated for a curriculum geared to the
lives of learners. Glasser made significant contribu-
tions through in-service workshops for teachers and
administrators. Since the late 1960s, reality therapy
has been further applied to education and to virtu-
ally all other human relationships, especially intimate
relationships. Most recently, reality therapy has been
applied to management and supervision, coaching,
family therapy, and parenting. It is now taught and
embedded on every continent except Antarctica.
Glasser became convinced that it was of para-
mount importance that clients accept personal
responsibility for their behavior. By the early 1980s,
Glasser was looking for a theory that could explain
all his work. Glasser learned about control theory from
William Powers, and he believed this theory had great
potential. He spent the next 10 years expanding,
revising, and clarifying what he was initially taught.
By 1996 Glasser had become convinced that these
revisions had so changed the theory that it was mis-
leading to continue to call it control theory, and he
changed the name to choice theory to reflect all that he
had developed. The essence of reality therapy, now
taught all over the world, is that we are all responsible
for what we choose to do. We are internally motivated
by current needs and wants, and we control our pres-
ent behavioral choices.
William Glasser
Co
ur
te
sy
o
f T
he
W
ill
ia
m
G
la
ss
er
In
st
itu
te
, C
ou
rt
es
y
of
Ro
be
rt
E
. W
ub
bo
ld
in
g
Ch
at
sw
or
th
, C
A
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 313
Introduction
Reality therapists believe the underlying problem for most clients is the
same: they are either involved in a present unsatisfying relationship or lack what
could even be called a relationship. Many client problems are caused by their inabil-
ity to connect, to get close to others, or to have a satisfying or successful relation-
ship with at least one significant person in their life. The therapist guides clients
toward a satisfying relationship and teaches them more effective ways of behaving.
The more clients are able to connect with people, the greater chance they have to
experience happiness.
Few clients understand that their problem, which is unhappiness, results from
the way they are choosing to behave. What they do know is that they feel a great
deal of pain or that they are unhappy because they have been sent for counseling by
someone with authority who is not satisfied with their behavior—typically a court
official, a school administrator, an employer, a spouse, or a parent. Reality therapists
recognize that clients choose their behaviors as a way to deal with the frustrations
caused by unsatisfying relationships.
Glasser (2003) maintained that clients should not be labeled with a diagnosis
except when it is necessary for insurance purposes. From Glasser’s perspective, diag-
noses are descriptions of the behaviors people choose in their attempt to deal with
LO1
shares his passion for his work and is
administrator of the Center for Reality
Therapy and editor of his writings.
Wubbolding is now the director of
the Center for Reality Therapy in Cin-
cinnati and faculty associate at Johns
Hopkins University. He is also professor
emeritus of Xavier University, where he
taught counselor education for 32 years.
He loved teaching and viewed his stu-
dents as being highly motivated, eager
to learn, and experienced. One of his
most meaningful experiences was teach-
ing graduate students in the counseling department
at Xavier University.
After completing his doctorate, Wubbolding
attended training sessions representing a wide range
of counseling approaches, yet he found reality ther-
apy to be best suited to his interests. He attended
many intensive training workshops conducted by
William Glasser in Los Angeles, and in 1988 Glasser
appointed him director of training for the William
Glasser Institute.
Wubbolding served as visiting professor at the
University of Southern California in their overseas
programs in Japan, Korea, and Germany,
thus fulfilling his lifelong desire to travel
and to live in other countries. He has
become an internationally known teacher,
author, and practitioner of reality therapy
and has introduced choice theory and real-
ity therapy in Europe, Asia, and the Middle
East. Among his specialties is adapting
choice theory and reality therapy to various
cultures and ethnic groups. He received
the Gratitude Award (2009) for Initiating
Reality Therapy in the United Kingdom
and the Certificate of Reality Therapy Psy-
chotherapist by the European Association for Psycho-
therapy (2009).
Wubbolding extended the theory and practice
of reality therapy with his conceptualization of the
WDEP system. He has written 14 books and more
than 150 articles, essays, and chapters in textbooks as
well as preparing more than 20 DVDs, some of which
are referenced in this chapter. His religious commit-
ment and his life of service to others are apparent in
his work, and he continues his vocation of teacher,
counselor, psychologist, and active member of his
church.
Robert E.
Wubbolding
Co
ur
te
sy
o
f R
ob
er
t E
. W
ub
bo
ld
in
g
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314 C H A P T E R E L E V E N
the pain and frustration that is endemic to their unsatisfying present relationships.
Labeling these ineffective behaviors as mental illness is inaccurate. Glasser limits the
term mental illness to conditions such as Alzheimer’s disease, epilepsy, head trauma,
and brain infections—conditions associated with tangible brain damage. Because
these people are suffering from a brain abnormality, Glasser’s view is that they
should be treated primarily by neurologists. Wubbolding tempers these principles,
advising counselors to follow standard practice and the standard of care regarding
diagnosis and use of psychiatric medications.
Reality therapy is based on choice theory as it is explained in several of Glasser’s
(1998, 2001, 2003) books. (In this chapter, the discussion of Glasser’s ideas pertains
to these three books, unless otherwise specified.) choice theory is the theoretical
basis for reality therapy; it explains why and how we function. reality therapy pro-
vides a delivery system for helping individuals take more effective control of their
lives. If choice theory is the highway, reality therapy is the vehicle delivering the prod-
uct (Wubbolding, 2011a). Therapy consists mainly of helping and sometimes teach-
ing clients to make more effective choices as they deal with the people they need in
their lives. It is essential for the therapist to establish a satisfying relationship with
clients as a prerequisite for effective therapy. Once this relationship is developed, the
skill of the therapist as listener and teacher assumes a central role.
Reality therapy has been used in a variety of settings. The approach is applicable
to counseling, social work, education, crisis intervention, corrections and rehabili-
tation, institutional management, and community development. Reality therapy is
popular in schools, state mental health hospitals, halfway houses, and alcohol and
drug abuse centers. Many of the military clinics that treat substance abusers use
reality therapy as their preferred therapeutic approach.
Visit CengageBrain.com or watch the DVD for the video program for Chapter 11, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. i suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Key Concepts
View of Human Nature
choice theory posits that we are not born blank slates waiting to be externally
motivated by forces in the world around us. Rather, we are born with five genetically
encoded needs that drive us all our lives: survival, or self-preservation; love and belong-
ing; power, or inner control; freedom, or independence; and fun, or enjoyment. Each of
us has all five needs, but they vary in strength. For example, we all have a need for love
and belonging, but some of us need more love than others. Choice theory is based
on the premise that because we are by nature social creatures we need to both receive
and give love. Glasser (2001, 2005) believes the need to love and to belong is the primary
need because we need people to satisfy the other needs. It is also the most difficult
need to satisfy because we must have a cooperative person to help us meet it.
Our brain functions as a control system. It continually monitors our feelings to
determine how well we are doing in our lifelong effort to satisfy these needs. When-
ever we feel bad, one or more of these five needs is unsatisfied. Although we may not
LO2
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 315
be aware of our needs, we know that we want to feel better. Driven by pain, we try to
figure out how to feel better. Reality therapists teach clients choice theory, sometimes
subtly and indirectly, so clients can identify unmet needs and try to satisfy them.
Choice theory teaches that we do not satisfy our needs directly. Beginning
shortly after birth and continuing all our lives, we keep close track of anything we
do that feels very good. We store information inside our minds and build a file of
wants, called our quality world, which is at the core of our life. It is our personal
Shangri-la—the world we would like to live in if we could. It is completely based on
our wants and needs, but unlike the needs, which are general, it is very specific. The
quality world consists of specific images of people, activities, events, beliefs, posses-
sions, and situations that fulfill our needs (Wubbolding, 2000, 2011a). In our qual-
ity world we develop an inner picture album of specific wants as well as precise ways
to satisfy these wants. We are attempting to behave in a way that gives us the most
effective control over our lives. Some pictures may be blurred, and the therapist’s
role is to help the client clarify them. Pictures exist in priority for most people, yet
clients may have difficulty identifying their priorities. Part of the process of reality
therapy is assisting clients in prioritizing their wants and uncovering what is most
important to them (Wubbolding, 2011a).
People we are closest to and most enjoy being with are the most important com-
ponent of our quality world, and we most want to connect with these people. Those
who enter therapy may have no one in their quality world or, more often, may have
someone in their quality world whom they are unable to relate to in a satisfying
way. For therapy to have a chance of success, a therapist must be the kind of person
that clients would consider putting in their quality world. Getting into the clients’
quality world is the art of therapy. It is from this relationship with the therapist that
clients begin to learn how to get close to the people they need.
Choice Theory Explanation of Behavior
Choice theory explains that all we ever do from birth to death is behave, and,
with some exceptions, everything we do is chosen or at least generated from within
ourselves. Every total behavior is our best attempt to get what we want to satisfy our
needs. total behavior teaches that all behavior is made up of four inseparable but
distinct components—acting, thinking, feeling, and physiology—that necessarily accom-
pany all of our actions, thoughts, and feelings. Choice theory emphasizes think-
ing and acting, which makes this a general form of cognitive behavior therapy. The
primary emphasis is on what the client is doing and how the doing component
influences the other aspects of total behavior. Behavior is purposeful because it is
designed to close the gap between what we want and what we perceive we are get-
ting. Specific behaviors are always generated from this discrepancy. Our behaviors
come from the inside, and thus we choose our destiny.
From Glasser’s perspective, to speak of being depressed, having a headache,
being angry, or being anxious implies passivity and lack of personal responsibility,
and it is inaccurate. It is more accurate to think of these as parts of total behaviors
and to use the verb forms depressing, headaching, angering, and anxietying to describe
them. It is more accurate to think of people depressing or angering themselves
rather than having the behaviors thrust upon them from the outside world. When
LO3
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316 C H A P T E R E L E V E N
people choose misery by developing a range of “paining” behaviors, it is because
these are the best behaviors they are able to devise at the time, and these behaviors
often get them what they want.
When a reality therapist starts teaching choice theory, the client will often pro-
test and say, “I’m suffering, don’t tell me I’m choosing to suffer like this.” As painful
as depressing is, the therapist explains that people do not choose pain and suffering
directly; rather, it is an unchosen part of their total behavior. The behavior of the
person is the best effort, ineffective as it is, to satisfy needs.
Robert Wubbolding (personal communication, April 4, 2015) has added a new
idea to choice theory. He believes that behavior is a language and that we send mes-
sages by what we are doing. The purpose of behavior is to influence the world to get
what we want. Therapists ask clients what messages they are sending to the world
by way of their actions: “What message do you want others to get?” “What message
are others getting whether or not you intended to send them?” By considering the
messages clients send to others, counselors can help clients indirectly gain a greater
appreciation of messages they unintentionally send to others.
Characteristics of Reality Therapy
The role of meaningful relationships in fostering emotional health is receiv-
ing increased attention in contemporary reality therapy, which quickly focuses on
the unsatisfying relationship or the lack of a relationship. Clients may complain of
not being able to keep a job, not doing well in school, or not having a meaningful
relationship. When clients complain about how other people are causing them pain,
reality therapists ask clients to consider how effective their choices are, especially as
these choices affect their relationships with significant people in their lives. Choice
theory teaches that talking about what clients cannot control is of minimal value;
the emphasis is on what clients can control in their relationships. The basic axiom
of choice theory, which is crucial for clients to understand, is that “the only person
you can control is yourself.”
Reality therapists spend little time listening to complaining, blaming, and crit-
icizing, for these are the most ineffective behaviors in our behavioral repertoire.
What do reality therapists focus on? Here are some underlying characteristics of
reality therapy.
Emphasize Choice and Responsibility Reality therapists see clients as being
responsible for their own choices as they have more control of their behavior than
they often believe. This does not mean people should be blamed or punished,
unless they break the law, but it does mean the therapist never loses sight of the fact
that clients are responsible for what they do. Choice theory changes the focus of
responsibility to choice and choosing.
Reality therapists deal with people “as if ” they have choices. Therapists focus
on those areas where clients have choice, for doing so gets them closer to the peo-
ple they need. For example, being involved in meaningful activities, such as work,
is a good way to gain the respect of other people, and work can help clients fulfill
their need for power. It is very difficult for adults to feel good about themselves
if they don’t engage in some form of meaningful activity. As clients begin to feel
LO4
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 317
good about themselves, it is less necessary for them to continue to choose ineffec-
tive and self-destructive behaviors.
Reject Transference Reality therapists strive to be themselves in their professional
work. By being themselves, therapists can use the relationship to teach clients how
to relate to others in their lives. Glasser contends that transference is a way that
both therapist and client avoid being who they are and owning what they are doing
right now. It is unrealistic for therapists to go along with the idea that they are
anyone but themselves. Assume the client claims, “I see you as my father or mother
and this is why I’m behaving the way I am.” In such a situation a reality therapist is
likely to say clearly and firmly, “I am not your mother, father, or anyone but myself.”
Wubbolding (personal communication, April 4, 2015) states that he discusses this
issue with clients in a detailed manner.
Keep the Therapy in the Present Some clients come to counseling convinced
that they must revisit the past if they are to be helped. Many therapeutic models
teach that to function well in the present people must understand and revisit their
past. Glasser (2001) disagrees with this assumption and contends that whatever
mistakes were made in the past are not pertinent now. An axiom of choice theory is
that the past may have contributed to a current problem but that the past is never
the problem. To function effectively, people need to live and plan in the present and
take steps to create a better future. We can only satisfy our needs in the present.
The reality therapist does not totally reject the past. If the client wants to talk
about past successes or good relationships in the past, the therapist will listen because
these may be repeated in the present. Reality therapists will devote only enough time
to past failures to assure clients that they are not rejecting them. As soon as pos-
sible, therapists tell clients, “What has happened is over; it can’t be changed. The
more time we spend looking back, the more we avoid looking forward.” Wubbolding
states, “history is not destiny” (personal communication, April 4, 2015). Although
the past has propelled us to the present, it does not have to determine our future. We
are free to make choices, even though our external world limits our choices (Wub-
bolding, 2011b).
Avoid Focusing on Symptoms In traditional therapy a great deal of time is spent
focusing on symptoms by asking clients how they feel and why they are obsessing.
Focusing on the past “protects” clients from facing the reality of unsatisfying
present relationships, and focusing on symptoms does the same thing. Whether
people are depressing or paining, they tend to think that what they are experiencing
is happening to them. They are reluctant to accept the reality that their suffering is
due to the total behavior they are choosing. Their symptoms can be viewed as the
body’s way of warning them that the behavior they are choosing is not satisfying
their basic needs. The reality therapist spends as little time as he or she can on the
symptoms because they will last only as long as they are needed to deal with an
unsatisfying relationship or the frustration of basic needs.
According to Glasser, if clients believe that the therapist wants to hear about
their symptoms or spend time talking about the past, they are more than willing to
comply. Engaging in long journeys into the past or exploring symptoms results in
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318 C H A P T E R E L E V E N
lengthy therapy. Glasser (2005) maintains that almost all symptoms are caused by a
present unhappy relationship. By focusing on present problems, especially interper-
sonal concerns, therapy can generally be shortened considerably.
Challenge Traditional Views of Mental Illness Choice theory rejects the
traditional notion that people with problematic physical and psychological
symptoms are mentally ill. Wubbolding (personal communication, April 4, 2015)
takes a firm stand on using the DSM-5 in creative ways and adhering to standard
practice, which includes diagnosing mental disorders. Glasser (2003), however, has
warned people to be cautious of psychiatry, which can be hazardous to both one’s
physical and mental health. He criticizes the traditional psychiatric establishment
for relying heavily on the DSM-5 (American Psychiatric Association, 2013) for both
diagnosis and treatment. Glasser (2003) challenges the traditionally accepted views
of mental illness and treatment by the use of medication, especially the widespread
use of psychiatric drugs that often results in negative side effects both physically and
psychologically. Wubbolding (personal communication, April 4, 2015) emphasizes
that reality therapy is a mental health system rather than a remediating system. He
incorporates the Ericksonian principle that “people don’t have problems, they have
solutions that have not worked.” By reframing diagnostic categories and negative
behaviors, the counselor helps clients perceive their behaviors in a very different
light, which facilitates the search for more effective solutions and choices.
The Therapeutic Process
Therapeutic Goals
A primary goal of contemporary reality therapy is to help clients get connected or recon-
nected with the people they have chosen to put in their quality world. In addition to
fulfilling this need for love and belonging, a basic goal of reality therapy is to help clients
learn better ways of fulfilling all of their needs, including achievement, power or inner
control, freedom or independence, and fun. The basic human needs serve to focus treat-
ment planning and setting both short- and long-term goals. Reality therapists assist cli-
ents in making more effective and responsible choices related to their wants and needs.
In many instances, clients come voluntarily for therapy, and these clients are the
easiest to help. However, another goal entails working with an increasing number
of involuntary clients who may actively resist the therapist and the therapy process.
These individuals often engage in violent behavior, addictions, and other kinds of
antisocial behaviors. It is essential for counselors to do whatever they can to connect
with involuntary clients. If the counselor is unable to make a connection, there is no
possibility of providing significant help. If the counselor can make a connection, the
goal of teaching the client how to fulfill his or her needs can slowly begin.
Therapist’s Function and Role
Therapy is often considered as a mentoring process in which the therapist
is the teacher and the client is the student. Reality therapists teach clients how to
engage in self-evaluation, which is done by raising the question, “Is what you are
LO5
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 319
choosing to do getting you what you want and need?” Here are some other ques-
tions that therapists tend to ask clients:
�� How would you most like to change your life?
�� What do you want in your life that you are not getting?
�� What would you have in your life if you were to change?
�� What do you have to do now to make the changes happen?
The role of the reality therapist is not to make the evaluation for clients but to
challenge clients to examine what they are doing. Reality therapists assist clients
in evaluating their own behavioral direction, specific actions, wants, perceptions,
level of commitment, possibilities for new directions, and action plans. Clients then
decide what to change and formulate a plan to facilitate the desired changes. The
outcome is better relationships, increased happiness, and a sense of inner control
over their life (Wubbolding, 2011b).
It is the job of therapists to convey the idea that no matter how bad things are
there is hope. If therapists are able to instill this sense of hope, clients feel that they
are no longer alone and that change is possible. The therapist functions as an advo-
cate, someone who is on the client’s side. Together they creatively address a range of
concerns and options.
Client’s Experience in Therapy
Clients are not expected to backtrack into the past or get sidetracked into talking
about symptoms. Neither will much time be spent talking about feelings separate
from the acting and thinking that are part of the total behaviors over which clients
have direct control. The emphasis is on actions. When clients change what they are
doing, they often change how they are feeling and thinking.
Reality therapists will gently, but firmly challenge clients. They often ask clients
questions such as these: “Is what you are choosing to do bringing you closer to the
people you want to be closer to right now?” “Is what you are doing getting you closer
to a new person if you are presently disconnected from everyone?” These questions
are part of the self-evaluation process, which is the cornerstone of reality therapy.
Clients can expect to experience some urgency in therapy. Time is important, as
each session may be the last. Clients should be able to say to themselves, “I can begin
to use what we talked about today in my life. I am able to bring my present experi-
ences to therapy as my problems are in the present, and my therapist will not let me
escape from that fact.”
Relationship Between Therapist and Client
Reality therapy emphasizes an understanding and supportive relationship, or thera-
peutic alliance, which is the foundation for effective outcomes. The therapist’s skill
in establishing a trusting relationship is critical. It is also important that the client
perceives the therapist as being skilled and knowledgeable. Although the therapeu-
tic relationship is paramount, it is not an end in itself, and it is not automatically
curative or healing (Wubbolding, 2011a).
For involvement between the therapist and the client to occur, the counselor
must have certain personal qualities, including warmth, sincerity, congruence,
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320 C H A P T E R E L E V E N
understanding, acceptance, concern, respect for the client, openness, and the willing-
ness to be challenged by others. (For other personal characteristics, see Chapter 2.)
Wubbolding (2011a, 2011b; 2015a) identifies specific ways for counselors to create
a climate that leads to involvement with clients. Some of these ways entail using
attending behavior, listening to clients, suspending judgment, doing the unex-
pected, using humor appropriately, being oneself as a counselor, engaging in facili-
tative self-disclosure, listening for metaphors in the client’s mode of self-expression,
listening for themes, summarizing and focusing, allowing consequences, allowing
silence, and being an ethical practitioner. For therapeutic interventions to work
effectively, a fair, firm, friendly, and trusting environment is necessary. Once involve-
ment has been established, the counselor assists clients in gaining a deeper under-
standing of the consequences of their current behavior.
Application: Therapeutic Techniques and Procedures
The Practice of Reality Therapy
The practice of reality therapy can best be conceptualized as the cycle of coun-
seling (Wubbolding, 2015a), which consists of two major components: (1) creating
the counseling environment and (2) implementing specific procedures that lead to
changes in behavior. The art of counseling is to weave these components together
in ways that lead clients to evaluate their lives and decide to move in more effective
directions.
How do these components blend in the counseling process? The cycle of
counseling begins with creating a working relationship with clients and proceeds
through an exploration of clients’ wants, needs, and perceptions. Clients explore
their total behavior and make their own evaluation of how effective they are in get-
ting what they want. If clients decide to try new behavior, they make plans that will
lead to change, and they commit themselves to those plans. The cycle of counseling
includes following up on how well clients are doing and offering further consulta-
tion as needed.
The concepts of reality therapy may seem simple as they are presented here, but
being able to translate these principles into therapeutic practice takes considerable
skill and creativity (Wubbolding, 2007, 2011b). All certified reality therapy counsel-
ors are grounded in the same principles, but the manner in which these principles are
applied varies depending on the counselor’s style and personal characteristics. These
principles are applied in a progressive manner, but they should not be thought of as
discrete and rigid categories. The art of practicing reality therapy involves far more
than following procedures in a step-by-step, cookbook fashion. With choice theory
in the background of practice, the counselor tailors the counseling to what each cli-
ent presents. Although the counselor is prepared to work in a way that is meaningful
to the client, the move toward satisfying relationships remains in the foreground.
Wubbolding has played a major role in the development of reality therapy and
has extended the practice of reality therapy through development of the WDEP sys-
tem (Wubbolding, 2009). I especially value Wubbolding’s contributions to teach-
ing reality therapy and to conceptualizing therapeutic procedures. His ideas render
choice theory practical and useable by counselors, and his system provides a basis
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 321
for conceptualizing and applying the theory. The Student Manual that accompanies
this textbook contains Wubbolding’s (2015a) chart, which diagrams the WDEP
model. It describes coaching, managing, supervising, and parenting and highlights
issues and tasks to be accomplished throughout the cycle of counseling. The follow-
ing sections are based on material from various sources (Glasser, 1992, 1998, 2001;
Wubbolding, 1988, 1991, 2000, 2007, 2011a, 2011b, 2013, 2015a; 2015c; Wubbold-
ing et al., 1998, 2004).
The Counseling Environment
The practice of reality therapy rests on the assumption that a supportive and chal-
lenging environment allows clients to begin making life changes. The therapeutic
relationship is the foundation for effective practice; if this is lacking, there is little
hope that the system can be successfully implemented. Counselors who hope to cre-
ate a therapeutic alliance strive to avoid arguing, attacking, accusing, demeaning,
blaming, bossing, criticizing, finding fault, coercing, encouraging excuses, holding
grudges, instilling fear, or giving up easily (Wubbolding, 2011a, 2011b, 2015a). In
a short period of time, clients generally begin to appreciate the caring, accepting,
noncoercive choice theory environment. It is from this mildly confrontive yet always
caring environment that clients learn to create the satisfying environment that leads
to successful relationships. In this coercion-free atmosphere, clients feel free to be
creative and to begin to try new behaviors.
Procedures That Lead to Change
Reality therapists operate on the assumption that we are motivated to change
(1) when we are convinced that our present behavior is not meeting our needs and
(2) when we believe we can choose other behaviors that will get us closer to what
we want. Reality therapists begin by asking clients what they want from therapy.
Therapists take the mystery and uncertainty out of the therapeutic process. They
also inquire about the choices clients are making in their relationships.
In the first session a skilled therapist looks for and defines the wants of the client.
The therapist also looks for a key unsatisfying present relationship—usually with a
spouse, a child, a parent, or an employer. The therapist might ask, “Whose behavior
can you control?” This question may need to be asked several times during the next
few sessions to deal with the client’s resistance to looking at his or her own behavior.
The emphasis is on encouraging the client to focus on what he or she can control.
When clients begin to realize that they can control only their own behavior, ther-
apy is under way. The rest of therapy focuses on how clients can make better choices.
There are more choices available than clients realize, and the therapist explores these
possible choices. Clients may be stuck in misery, blaming, and the past, but they
can choose to change—even if the other person in the relationship does not change.
Wubbolding (2011a) points out that clients can learn they are not at the mercy of
others, are not victims, are capable of gaining a sense of inner control, and have a
range of choices open to them. In short, clients in reality therapy often acquire a
sense of hope for a better future.
Reality therapists explore the tenets of choice theory with clients, helping them
identify basic needs, discovering their quality world, and, finally, helping clients
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322 C H A P T E R E L E V E N
understand that they are choosing the total behaviors that are their symptoms. In
every instance when clients make a change, it is their choice. With the therapist’s
help, clients learn to make better choices than they did when they were on their own.
Through choice theory, clients can acquire and maintain successful relationships.
The “WDEP” System
Wubbolding (2000, 2015a, 2015c) uses the acronym WDEP to describe key proce-
dures in the practice of reality therapy. The WDEP system can be used to help clients
explore their wants, possible things they can do, opportunities for self-evaluation, and
design plans for improvement (Wubbolding, 2007, 2011a, 2011b, 2015b, 2015c).
Grounded in choice theory, the WDEP system assists people in satisfying their basic
needs. Each of the letters refers to a cluster of strategies: W = wants, needs, and
perceptions; D = direction and doing; E = self-evaluation; and P = planning. These
strategies are designed to promote change. Let’s look at each one in more detail.
Wants (Exploring Wants, Needs, and Perceptions) Reality therapists assist
clients in discovering their wants and hopes. All wants are related to the five basic
needs. The key question asked is, “What do you want?” Through the therapist’s
skillful questioning, clients are assisted in defining what they want from the
counseling process and from the world around them. It is useful for clients to
define what they expect and want from the counselor and from themselves. Part of
counseling consists of exploring the “picture album,” or quality world, of clients
and how their behavior is aimed at moving their perception of the external world
closer to their inner world of wants.
Clients are given the opportunity to explore every facet of their lives, including
what they want from their family, friends, and work. Furthermore, this exploration
of wants, needs, and perceptions should continue throughout the counseling pro-
cess as clients’ pictures change.
Here are some useful questions to help clients pinpoint what they want:
�� If you were the person that you wish you were, what kind of person
would you be?
�� What would your family be like if your wants and their wants matched?
�� What would you be doing if you were living as you want to live?
�� Do you really want to change your life?
�� What is it you want that you don’t seem to be getting from life?
�� What do you think stops you from making the changes you would
like?
Wubbolding and Brickell (2009) and Gerdes, Wubbolding, and Wubbolding
(2012, p. 51) now include questions focused on perceptions:
�� How do you look at the situation?
�� Where do you see your control?
People have a great deal more control than they often perceive, and these ques-
tions help clients move from a sense of external control to a sense of internal con-
trol. This line of questioning sets the stage for applying other procedures in reality
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 323
therapy. It is an art for counselors to know what questions to ask, how to ask them,
and when to ask them. Relevant questions help clients gain insights and arrive at
plans and solutions. Although well-timed, open-ended questions can help clients
identify their counseling goals, excessive questioning can result in resistance and
defensiveness. In this phase of counseling, clients begin to commit to making
changes in their behavior.
Direction and Doing The focus on the present is characterized by the key question
asked by the reality therapist: “What are you doing?” Even though problems may be
rooted in the past, clients need to learn how to deal with them in the present by
learning better ways of getting what they want. Problems must be solved either in
the present or through a plan for the future. The therapist’s challenge is to help
clients make more need-satisfying choices.
Early in counseling it is essential to discuss with clients the overall direction of
their lives, including where they are going and where their behavior is taking them.
This exploration is preliminary to the subsequent evaluation of whether it is a desir-
able direction. The therapist holds a mirror before the client and asks, “What do you
see for yourself now and in the future?” It often takes some time for this reflection to
become clearer to clients so they can verbally express their perceptions.
Reality therapy focuses on gaining awareness of and changing current total
behavior. To accomplish this, reality therapists focus on questions like these: “What
are you doing now?” “What did you actually do yesterday?” “What did you want to
do differently this past week?” “What stopped you from doing what you said you
wanted to do?” “What will you do tomorrow?”
Listening to clients talk about feelings can be productive, but only if it is linked
to what they are doing. When an emergency light on the car dashboard lights up,
the driver is alerted that something is wrong and that immediate action is necessary
to remedy a problem. In a similar way, when clients talk about problematic feelings,
most reality therapists affirm and acknowledge these feelings. Rather than focusing
mainly on these feelings, however, reality therapists encourage clients to take action
by changing what they are doing and thinking. It is easier to change what we are
doing and thinking than to change our feelings. From a choice theory perspective,
discussions centering on feelings, without strongly relating them to what people are
doing and thinking, are counterproductive.
Self-Evaluation self-evaluation is the cornerstone of reality therapy procedures.
“Conducting a searching and fearless self-evaluation is the royal road to behavioral
change” (Wubbolding, 2015c, p. 860). Clients are asked to make the following self-
evaluation: “Does your present behavior have a reasonable chance of getting you what
you want now, and will it take you in the direction you want to go?” This evaluation
involves the client examining behavioral direction, specific actions, wants, perceptions,
new directions, and plans (Wubbolding, 2011b, 2015b). Wubbolding believes that
clients often present a problem with a significant relationship, which is at the root of
much of their dissatisfaction. The counselor can help clients evaluate their behavior
by asking this question: “Is your current behavior bringing you closer to people
important to you or is it driving you further apart?” Through skillful questioning, the
counselor helps clients determine if what they are doing is helping them.
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324 C H A P T E R E L E V E N
Artful questioning assists clients in evaluating their present behavior and the
direction this is taking them. Wubbolding (2000, 2011a, 2015b) suggests questions
like these:
�� Is what you are doing helping or hurting you?
�� Is what you are doing now what you want to be doing?
�� Is your behavior working for you?
�� Is there a healthy congruence between what you are doing and what you
believe?
�� Is what you are doing against the rules?
�� Is what you want realistic or attainable?
�� Does it help you to look at it that way?
�� Is it really true that you have no control over your situation?
�� How committed are you to the therapeutic process and to changing
your life?
�� After carefully examining what you want, does it appear to be in your
best interests and in the best interest of others?
Asking clients to evaluate each component of their total behavior is a major task
in reality therapy. It is the counselor’s task to assist clients in evaluating the quality
of their actions and to help them make responsible choices and devise effective plans.
Individuals will not change until they first decide that a change would be more
advantageous. Without an honest self-assessment, it is unlikely that clients will
change. Reality therapists are relentless in their efforts to help clients conduct explicit
self-evaluations of each behavioral component. When therapists ask a depressing
client if this behavior is helping in the long run, they introduce the idea of choice to
the client. The process of evaluation of the doing, thinking, feeling, and physiologi-
cal components of total behavior is within the scope of the client’s responsibility.
Reality therapists may be directive with certain clients at the beginning of treat-
ment to help clients recognize that some behaviors are not effective. In working with
clients who are in crisis, for example, it is sometimes necessary to suggest straight-
forwardly what will work and what will not. Other clients, such as alcoholics and
children of alcoholics, need direction early in the course of treatment, for they often
do not have the thinking behaviors in their control system to be able to make con-
sistent evaluations of when their lives are seriously out of effective control. These
clients are likely to have blurred pictures and, at times, to be unaware of what they
want or whether their wants are realistic. As they grow and continue to interact with
the counselor, they learn to make evaluations with less and less help from the coun-
selor (Wubbolding, 2011a; Wubbolding & Brickell, 2005).
Planning and Action Much of the significant work of the counseling process
involves helping clients identify specific ways to fulfill their wants and needs. Once
clients determine what they want to change, they are generally ready to explore other
possible behaviors and formulate an action plan. The key question is, “What is your
plan?” The process of creating and carrying out plans enables people to begin to
gain effective control over their lives. If the plan does not work, for whatever reason,
the counselor and client work together to devise a different plan. The plan gives
the client a starting point, a toehold on life, but plans can be modified as needed.
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 325
Throughout this planning phase, the counselor continually urges the client to be
willing to accept the consequences for his or her own choices and actions. Not only
are plans discussed in light of how they can help the client personally, but plans are
also designed in terms of how they are likely to affect others in the client’s life.
Wubbolding (2000, 2007, 2011a, 2011b, 2013, 2015b) discusses the central role
of planning and commitment. The culmination of the cycle of counseling rests with
a plan of action. Although planning is important, it is effective only if the client has
made a self-evaluation and determined that he or she wants to change a behavior.
Wubbolding uses the acronym SAMIC to capture the essence of a good plan: simple,
attainable, measurable, immediate, involved, controlled by the planner, committed
to, and consistently done. Wubbolding contends that clients gain more effective
control over their lives with plans that have the following characteristics:
�� The plan is within the limits of the motivation and capacities of the cli-
ent. Skillful counselors help clients identify plans that involve greater
need-fulfilling payoffs. Clients may be asked, “What plans could you
make now that would result in a more satisfying life?”
�� Good plans are simple and easy to understand. They are realistically
doable, positive rather than negative, dependent on the planner, spe-
cific, immediate, and repetitive. Although they need to be specific, con-
crete, and measurable, plans should be flexible and open to revision as
clients gain a deeper understanding of the specific behaviors they want
to change.
�� The plan involves a positive course of action, and it is stated in terms of
what the client is willing to do. Even small plans can help clients take
significant steps toward their desired changes.
�� Counselors encourage clients to develop plans that they can carry out
independently of what others do. Plans that are contingent on others
lead clients to sense that they are not steering their own ship but are at
the mercy of the ocean.
�� Effective plans are repetitive and, ideally, are performed daily.
�� Plans are carried out as soon as possible. Counselors can ask the ques-
tion, “What are you willing to do today to begin to change your life?”
�� Plans involve process-centered activities. For example, clients may plan
to do any of the following: apply for a job, write a letter to a friend,
take a yoga class, substitute nutritious food for junk food, devote two
hours a week to volunteer work, or take a vacation that they have been
wanting.
�� Before clients carry out their plan, it is a good idea for them to evaluate
it with their therapist to determine whether it is realistic and attainable
and whether it relates to what they need and want. After the plan has
been carried out in real life, it is useful to evaluate it again and make
any revisions that may be necessary.
�� To help clients commit themselves to their plan, it is useful for them to
firm it up in writing.
Resolutions and plans are empty unless there is a commitment to carry them out.
It is up to clients to determine how to take their plans outside the restricted world
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326 C H A P T E R E L E V E N
of therapy and into the everyday world. Effective therapy can be the catalyst that
leads to self-directed, responsible living.
Asking clients to determine what they want for themselves, to make a self-
evaluation, and to follow through with action plans includes assisting them in
determining how intensely they are willing to work to attain the changes they desire.
Commitment is not an all-or-nothing matter; it exists in degrees. Wubbolding
(2007, 2011a, 2011b) maintains that it is important for a therapist to ask about
clients’ level of commitment, or how much they are willing to work to bring about
change. This communicates in an implicit way to clients that they have within them
the power to take charge of their lives. It is essential that those clients who are reluc-
tant to make a commitment be helped to express and explore their fears of failing.
Clients are helped by a therapist who does not easily give up believing in their ability
to make better choices, even if they are not always successful in completing their
plans. In his workshops, Wubbolding often mentions this axiom of reality therapy:
“To fail to plan is to plan to fail.”
Application to Group Counseling
With the emphasis on connection and interpersonal relationships, real-
ity therapy is well suited for various kinds of group counseling. Groups provide
members with many opportunities for exploring ways to meet their needs through
the relationships formed within the group. In particular, the WDEP system can
be applied to helping group members satisfy their basic needs. If members talk
about their past experiences or make excuses for their current behavior, the group
leader redirects them to what they are presently doing. From the very beginning of
a group, the members can be asked to take an honest look at what they are doing
and to clarify whether their behavior is getting them what they say they want.
Once group members get a clearer picture of what they have in their life now and
what they want to be different, they can use the group as a place to explore alter-
native courses of behavior.
This model lends itself to expecting the members to carry out homework assign-
ments between the group meetings. However, it is the members, with the help of the
leader, who evaluate their own behavior and decide whether they want to change
some aspect of their life. Members also take the lead in deciding what kinds of
homework tasks they will set for themselves as a way to achieve their goals. Group
leaders often meet with resistance if they make poorly timed suggestions and plans
for how the members should best live. To their credit, reality therapists continue
asking the members to evaluate for themselves whether what they are doing is get-
ting them what they want. If the members concede that what they are doing is not
working for them, their resistance is much more likely to melt, and they tend to be
more open to trying different behaviors.
Once the members make some changes, reality therapy provides the structure
for them to formulate specific plans for action and to evaluate their level of success.
Feedback from the members and the leader can help individuals design realistic and
attainable plans. Considerable time is devoted during the group sessions for devel-
oping and implementing plans. If people do not carry out a plan, it is important to
discuss with them what stopped them. Perhaps they set their goals unrealistically
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 327
high, or perhaps there is a discrepancy between what they say they want to change
and the steps they are willing to take to bring about change.
I also like reality therapy’s insistence that change will not come by insight alone;
rather, members have to begin doing something different once they determine that
their behavior is not working for them. I am skeptical about the value of catharsis
as a therapeutic vehicle unless the release of pent-up emotions is eventually put into
some kind of cognitive framework and is followed up with an action plan. In the
groups that I facilitate, group members are challenged to look at the futility of wait-
ing for others to change. I ask members to assume that the significant people in their
life may never change, which means that they will have to take a more active stance
in shaping their own destiny. I appreciate the emphasis of reality therapy on teach-
ing clients that the only life they can control is their own and the focus placed on
helping group members change their own patterns of acting and thinking.
For a more detailed discussion of reality therapy in groups, see Corey (2016,
chap. 15).
Choice Theory/Reality Therapy From a Multicultural
Perspective
Strengths From a Diversity Perspective
The core principles of choice theory and reality therapy have much to offer
in the area of multicultural counseling. In cross-cultural therapy it is essential that
counselors respect the differences in worldview between themselves and their clients.
Counselors demonstrate their respect for the cultural values of their clients by help-
ing them explore how satisfying their current behavior is both to themselves and to
others. Once clients make this assessment, they can formulate realistic plans that are
consistent with their cultural values. It is a further sign of respect that the counselor
refrains from deciding what specific behaviors should be changed. Through skillful
questioning on the counselor’s part, clients from diverse ethnic backgrounds can be
helped to determine the degree to which they have become acculturated into the dom-
inant society. Is it possible for them to find a balance, retaining their ethnic identity
and values while integrating some of the values and practices of the dominant group?
Again, the counselor does not determine this balance for clients, but works with them
to arrive at their own answers. With this focus on thinking and acting rather than on
exploring feelings, many clients are less likely to display resistance to counseling.
Wubbolding (2007, 2011a, 2011b) asserts that the principles underlying choice
theory are universal, which makes choice theory applicable to all people. We are all
members of the same species and have the same genetic structure; therefore, rela-
tionships are the problem in all cultures. All of us have internal needs, we all make
choices, and we all seek to influence the world around us. Putting the principles of
choice theory into action demands creativity, sensitivity to cultures and individuals,
and flexibility in implementing the procedures of reality therapy. Reality therapy
principles and procedures need to be applied differently in various cultures and
must be adapted to the psychological and developmental levels presented by indi-
viduals (Wubbolding, 2011b).
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328 C H A P T E R E L E V E N
Based on the assumption that reality therapy must be modified to fit the cul-
tural context of people other than North Americans, Wubbolding (2000, 2011a) and
Wubbolding and colleagues (1998, 2004) have expanded the practice of reality therapy
to multicultural situations. Wubbolding’s experience in conducting reality therapy
workshops in Japan, Taiwan, Hong Kong, Singapore, Korea, India, Kuwait, Morocco,
Malta, Romania, Australia, Slovenia, Croatia, and countries in western Europe has
taught him the difficulty of generalizing about other cultures. Growing out of these
multicultural experiences, Wubbolding (2000) has adapted the cycle of counseling in
working with Japanese clients. He points to some basic language differences between
Japanese and Western cultures. North Americans are inclined to say what they mean
and to be assertive. In Japanese culture, assertive language is not appropriate between
a child and a parent or between an employee and a supervisor. Ways of communicat-
ing are more indirect. To ask some Japanese clients what they want may seem harsh
and intrusive to them. Because of these style differences, adaptations may be needed
to make the practice of reality therapy relevant to Japanese clients:
�� The reality therapist’s tendency to ask direct questions may need to be
softened, with questions being raised more elaborately and indirectly. It
may be a mistake to ask individualistic questions built around whether
specific behaviors meet the client’s need. Confrontation should be done
only after carefully considering the context.
�� There is no exact Japanese translation for the word “plan,” nor is there
an exact word for “accountability,” yet both of these are key dimensions
in the practice of reality therapy and are central to Japanese culture.
�� In asking clients to make plans and commit to them, Western counsel-
ors do not settle for a response of “I’ll try.” Instead, they tend to push
for an explicit pledge to follow through. In Japanese culture, however,
the counselor is likely to accept “I’ll try” as a firm commitment.
These are but a few illustrations of ways in which reality therapy might be
adapted to non-Western clients. Even though all people have the same basic needs
(survival, love and belonging, power, freedom, and fun), the way these needs are
expressed depends largely on the cultural context. In working with culturally diverse
clients, the therapist must allow latitude for a wide range of acceptable behaviors to
satisfy these needs. As with other theories and the techniques that flow from them,
flexibility is a foremost requirement.
A key strength of reality therapy is that it provides clients with tools to make the
changes they desire. This is especially true during the planning phase, which is cen-
tral to the process of reality therapy. The focus is on positive steps that can be taken,
not on what cannot be done. Clients identify those problems that are causing them
difficulty, and these problems become the targets for change. This type of specificity
and the direction that is provided by an effective plan are certainly assets in working
with diverse client groups. Reality therapy is an open system that allows for flexibil-
ity in application based on the needs of culturally diverse individuals.
Reality therapy needs to be used artfully and to be applied in different ways with a
variety of clients. Many of its principles and concepts can be incorporated in a dynamic
and personal way in the style of counselors, and there is a basis for integrating these
concepts with most of the other therapeutic approaches covered in this book.
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 329
Shortcomings From a Diversity Perspective
One of the shortcomings of reality therapy in working with clients from certain
ethnic groups is that it may not take fully into account some very real environmen-
tal forces that operate against them in their everyday lives. Counselors need to be
broadly trained and be able to compensate for the limitation inherent in all counsel-
ing theories, Reality therapy gives only limited attention to helping people address
environmental and social problems. Discrimination, racism, sexism, homophobia,
heterosexism, ageism, negative attitudes toward disabilities, and other social injus-
tices are unfortunate realities, and these forces do limit many individuals in getting
what they want from life. It is important that therapists acknowledge that people
do not choose to be the victims of various forms of discrimination and oppression.
If therapists do not accept these environmental restrictions or are not interested in
bringing about social justice as well as individual change, clients are likely to feel
misunderstood. There is a danger that some reality therapists may overstress the
ability of these clients to take charge of their lives and not pay enough attention to
systemic and environmental factors that can limit the potential for choice.
Some reality therapists may make the mistake of too quickly or too force-
fully stressing the ability of their clients to take charge of their lives. On this point,
Wubbolding (2013) maintains that because of oppression and discrimination, some
people have fewer choices available to them, yet they do have choices. Although focus-
ing on choices clients do have is useful, I believe clients may need to talk about the
ways their choices are restricted by environmental circumstances. Therapists would
do well to consider how both they and their clients could take even small steps toward
bringing about societal changes, as do feminist therapists (see Chapter 12).
Another shortcoming associated with reality therapy is that some clients are very
reluctant to directly verbally express what they need. Their cultural values and norms
may not reinforce them in assertively asking for what they want. In fact, they may be
socialized to think more of what is good for the social group than of their individual
wants. In working with people with these values, counselors must “soften” reality ther-
apy somewhat. If reality therapy is to be used effectively with clients from other cul-
tures, the procedures must be adapted to the life experiences and values of members
from various cultures (Wubbolding, 2000, 2011a; Wubbolding et al., 2004).
As a reality therapist, I am guided by the key con-cepts of choice theory to identify Stan’s behav-
ioral dynamics, to provide a direction for him to work
toward, and to teach him about better alternatives for
achieving what he wants. Stan has not been effective in
getting what he needs—a satisfying relationship.
Stan has fallen into a victim role, blaming others,
and looking backward instead of forward. Initially, he
wants to tell me about the negative aspects of his life,
which he does by dwelling on his major symptoms:
depression, anxiety, inability to sleep, and other psy-
chosomatic symptoms. I listen carefully to his con-
cerns, but I hope he will come to realize that he has
many options for acting differently. I operate on the
premise that therapy will offer the opportunity to ex-
plore with Stan what he can build on—successes, pro-
ductive times, goals, and hopes for the future.
After creating a relationship with Stan, I am able
to show him that he does not have to be a victim of
his past unless he chooses to be, and I assure him that
Reality Therapy Applied to the Case of Stan
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330 C H A P T E R E L E V E N
Visit CengageBrain.com or watch the DVD for
Theory and Practice of Counseling and Psychotherapy:
The Case of Stan and Lecturettes, Session 9 (reality
therapy), for a demonstration of my approach to
counseling Stan from this perspective. This session
deals with assisting Stan in forming an action plan.
he has rehashed his past miseries enough. As counsel-
ing progresses, Stan learns that even though most of
his problems did indeed begin in childhood, there is
little he can do now to undo his childhood. However,
he can adopt a different perspective on his past experi-
ences and the meaning they hold for him today. He
eventually realizes that he has a great deal of control
over what he can do for himself now.
I have Stan describe how his life would be differ-
ent if he were symptom free. I am interested in knowing
what he would be doing if he were meeting his needs
for belonging, achievement, power, freedom, and fun.
I explain to him that he has an ideal picture of what he
wants his life to be, yet he does not possess effective be-
haviors for meeting his needs. I talk to him about all
of his basic psychological needs and how this type of
therapy will teach him to satisfy them in effective ways.
I also explain that his total behavior is made up of acting,
thinking, feeling, and physiology. Even though he says
he hates feeling anxious most of the time, Stan learns
that much of what he is doing and thinking is directly
leading to his unwanted feelings and physiological reac-
tions. When he complains of feeling depressed much of
the time, anxious at night, and overcome by panic at-
tacks, I let him know that I am more interested in what
he is doing and thinking because these are the behavioral
components that can be directly changed.
I help Stan understand that his depressing is the feel-
ing part of his choice. Although he may think he has lit-
tle control over how he feels, over his bodily sensations,
and over his thoughts, I want him to understand that
he can begin to take different action, which is likely to
change his depressing experience. I frequently ask this
question, “Is what you are choosing to do getting you
what you want?” I lead Stan to begin to recognize that
he does have some, indirect control over his feelings. This
is best done after he has made some choices about do-
ing something different from what he has been doing.
At this point he is in a better place to see that the choice
to take action has contributed to feeling better, which
helps him realize that he has some power to change.
Stan tells me about the pictures in his head, a few
of which are becoming a counselor, acting confident in
meeting people, thinking of himself as a worthwhile
person, and enjoying life. Through therapy he makes
the evaluation that much of what he is doing is not get-
ting him closer to these pictures or getting him what
he wants. After he decides that he is willing to work on
himself to be different, the majority of time in the ses-
sions is devoted to making plans and discussing their
implementation. We both focus on the specific steps he
can take right now to begin the changes he would like.
As Stan continues to carry out plans in the real
world, he gradually begins to experience success. When
he does backslide, we talk about this and together help
him fine tune his plan. I am not willing to give up on
Stan even when he does not make major progress, and
Stan lets me know that my support is a source of real
inspiration for him to keep working on himself.
I teach Stan about choice theory and encourage
him to do some reading that can stimulate his think-
ing about changes in his life. Stan brings some of what
he is learning from his reading into his sessions, and
eventually he is able to achieve some of his goals. The
combination of working with a reality therapist, his
reading, and his willingness to put what he is learn-
ing into practice by engaging in new behaviors in the
world assist him in replacing ineffective choices with
life-affirming choices. Stan comes to accept that he is
the only person who can control his destiny.
Questions for Reflection
�� If Stan complains of feeling depressed most of the
time and wants you to “fix” him, how would you
proceed?
�� If Stan persists, telling you that his mood is get-
ting the best of him and that he wants you to work
with his physician in getting him on an antide-
pressant drug, what would you say or do?
�� What are some of Stan’s basic needs that are not
being met? What action plans can you think of to
help Stan find better ways of getting what he wants?
�� Would you be inclined to do a checklist on alcoholism
with Stan? Why or why not? If you determined that
he was addicted to alcohol, would you insist that he
attend a program such as Alcoholics Anonymous in
conjunction with therapy with you? Why or why not?
�� What interventions would you make to help Stan
explore his total behavior?
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 331
Gwen has lived for a long time believing therapy was for weak and crazy people, and certainly not
for an African American woman of strong faith. Gwen
has not been in therapy before, and I need to establish
a climate of trust and respect so she feels it is safe to ex-
press her feelings. As we develop our working alliance,
I help Gwen understand that she has already begun
the change process by doing something different and
coming in for therapy.
Therapist: Tell me what you want your life to be like?
[Inquiry about her quality world]
Gwen: I want to feel appreciated and relaxed. I don’t
want work to be the most important aspect of my
life. I want to feel strong and healthy in my body.
I am tired of feeling achy and overwhelmed. I want
to feel respected and loved by my family. I am tired
of feeling like I have to do everything alone.
Therapist: Think back over this past week and tell me
something you did to move yourself closer to the
life you want.
Gwen: I took a beginner’s yoga class, and it helped me
relax. I didn’t feel as achy the next day, so I signed up
for an eight-week class. [Gwen tries out a new behavior]
Therapist: That’s great. I am proud of you! You sound
committed.
Gwen has gotten into the habit of letting life hap-
pen to her rather than taking the steering wheel and
driving in the direction of her hopes and dreams. For
real change to occur, Gwen must “do” something dif-
ferent. The yoga class is a good start for her plan.
Therapist: Now think about what you can do differ-
ently in another aspect of your life to move closer
to your ideal scene.
Gwen: I feel like I am doing a lot already.
Therapist: You are doing a lot. Is that what you want
to continue to do? [A reality check]
Gwen: I know I need to prioritize my life and put
myself first. I know I take on too much. It’s a bad
habit, and it is wearing me out. [Self-evaluation]
Therapist: How well is taking on the role of a martyr
working for you? [No criticism is implied]
Gwen: Not at all! I watched my grandmother wear
herself out taking care of the entire family. I need
to pull back.
I will not abandon Gwen if she does not meet her
goals or if her plans are unsuccessful. I do challenge
her in an empathic and supportive manner to discuss
what she can do to get back on course. I stay commit-
ted to Gwen and help her make the small incremental
changes that she desires.
Therapist: What are you willing to do differently this
week that you can commit to?
Gwen: I can make sure I get more time for myself. I
will definitely do the yoga at least twice a week to
help me with my flexibility and stress management.
I can set up Meals on Wheels for my mom. That
could really free up some of my time.
Therapist: Those are good first steps. You are on your
way to creating a healthy action plan for your life.
Taking these steps can help relieve some of the
anxiety you have been feeling. I will check in with
you next week at the beginning of our session to
see how well you carried out your plan.
Before she leaves, I encourage Gwen to consider
reading a book I suggest. We will build on her action
plan at the next session.
Therapist: Do you think you could find time to read
a short book that is easy to read? [I give her Wub-
bolding’s book, A Set of Directions for Putting and
Keeping Yourself Together] This will give you some
ideas on action steps you might want to take in
other areas of your life. Start by picking just one or
two of the activities that you think you can use.
Gwen: What other changes do you think I should
make?
The success of our work together depends not only
on my skill and ability to establish a relationship with
Gwen but also on her willingness to take responsibility
Reality Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing using a reality therapy perspective and applying this model to Gwen.
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Summary and Evaluation
Summary
The reality therapist functions as a teacher, a mentor, and a model, confront-
ing clients in ways that will help them evaluate what they are doing and whether
their behavior is fulfilling their basic needs without harming themselves or oth-
ers. The heart of reality therapy is learning how to make better and more effective
choices and gain more effective control. People take charge of their lives rather than
being the victims of circumstances beyond their control. Practitioners of reality
therapy focus on what clients are able and willing to do in the present to change their
behavior. Practitioners teach clients how to make significant connections with oth-
ers. Therapists continue to ask clients to evaluate the effectiveness of what they are
choosing to do to determine if better choices are possible.
The practice of reality therapy weaves together two components, the counseling
environment and specific procedures that lead to changes in behavior. This thera-
peutic process enables clients to move in the direction of getting what they want.
The goals of reality therapy include behavioral change, better decision making,
improved significant relationships, enhanced living, and more effective satisfaction
of all the psychological needs.
Contributions of Choice Theory/Reality Therapy
Among the advantages of reality therapy are its relatively short-term focus and the
fact that it deals with conscious behavioral problems. Insight and awareness are
not enough; the client’s self-evaluation, a plan of action, and a commitment to fol-
lowing through are the core of the therapeutic process. I like the focus on strongly
332 C H A P T E R E L E V E N
for her behavior and her willingness to make alterna-
tive choices. I want to support Gwen as she discovers
her own answers to that question. I refrain from tell-
ing her what to choose for her action plan. Her success
must come from her own evaluation of what needs to
shift in her life.
Therapist: This is your journey, and you know best
what changes could be beneficial for you. Keep
your hands on the steering wheel of your life and
notice how you begin to feel once you get in the
habit of saying, “yes” to your health and well-being.
Take things slowly. There is no need to rush and
make a lot of changes right away.
I hope Gwen will notice a difference in her anxiety
level as she begins to implement her action plan. As
she feels more comfortable with taking charge of her
life, I believe that she will be able to tackle more signifi-
cant changes, such as setting clear boundaries with her
adult children. Gwen is beginning to venture down a
new road. She is stepping up to a new level of personal
responsibility and is moving away from being a passive
victim of her life circumstances.
Questions for Reflection
�� What interventions did the therapist make to help
Gwen evaluate her current behavior?
�� Assess the usefulness of this question in working
with Gwen: “Is what you’re doing helping you get
what you want?”
�� To what degree do you think Gwen is ready to
make an action plan?
�� How would you describe the interaction and the
relationship between the therapist and Gwen.
LO9
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 333
encouraging clients to engage in self-evaluation, to decide if what they are doing
is working or not, and to commit themselves to doing what is required to make
changes they desire. The existential underpinnings of choice theory are a major
strength of this approach, which accentuates taking responsibility for what we are
doing. People are not viewed as being hopelessly and helplessly depressed. Instead,
people are viewed as doing the best they can, or making the choices they hope will
result in fulfilling their needs. With the emphasis on responsibility and choice, indi-
viduals can acquire a sense of self-direction and empowerment.
Too often counseling fails because therapists have an agenda for clients. The
reality therapist helps clients conduct a searching inventory of what they are doing.
If individuals determine that their present behavior is not working, they are then
much more likely to consider acquiring a new behavioral repertoire. Many clients
approach counseling with a great deal of skepticism. Reality therapy can be used
effectively with individuals who manifest reluctance and ambivalence to change.
For example, in working with people with addictions, reality therapy strategies can
be used to help clients evaluate where their behavior is leading them and to pro-
vide clients with options to bring about positive changes in their behavior. Reality
therapy has been effectively used in addiction treatment and recovery programs
for more than 30 years (Wubbolding & Brickell, 2005). With these populations, it
would be inappropriate to embark on long-term therapy that delves into uncon-
scious dynamics and an intensive exploration of one’s past. Addressing what clients
are presently doing and asking clients to evaluate what they want to change fits
well in various settings. Reality therapy is an effective, short-term approach, often
requiring 10 sessions or less, that can enable people to make life changes without
prolonged therapy.
Limitations and Criticisms of Choice Theory/Reality Therapy
From my perspective, one of the main limitations of reality therapy is that it does
not give adequate emphasis to the role of the following aspects of the counseling
process: the role of insight, the unconscious, the power of the past and the effect
of traumatic experiences in early childhood, the therapeutic value of dreams, and
the place of transference. Because reality therapy focuses almost exclusively on con-
sciousness, it does not take into account factors such as repressed conflicts and the
power of the unconscious in influencing how we think, feel, behave, and choose.
Dealing with dreams is not part of the reality therapist’s repertoire. According
to Glasser (2001), it is not therapeutically useful to explore dreams, an idea which I
find limiting in this approach. For him, spending time discussing dreams can be a
defense used to avoid talking about one’s behavior and, thus, is time wasted. From
my perspective, dreams are powerful tools in helping people recognize their inter-
nal conflicts. I believe that there is richness in dreams, which can be a shorthand
message of clients’ central struggles, wants, hopes, and visions of the future. Asking
clients to recall, report, share, and relive their dreams in the here and now of the
therapeutic session can help unblock them and can pave the way for clients to take
a different course of action.
Similarly, I have a difficult time accepting Glasser’s view of transference as a
misleading concept, for I find that clients are able to learn that significant people in
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334 C H A P T E R E L E V E N
their lives have a present influence on how they perceive and react to others. To rule
out an exploration of transference that distorts accurate perception of others seems
narrow in my view.
I believe reality therapy is vulnerable to the practitioner who assumes the role
of an expert in deciding for others how life should be lived and what constitutes
responsible behavior. Wubbolding (2013) admits that reality therapy can lend itself
to fixing problems and imposing a therapist’s values on clients, especially by inex-
perienced or inadequately trained counselors. Wubbolding adds that it is not the
therapist’s role to evaluate the behavior of clients. Generally, clients need to engage
in a process of courageous self-evaluation to determine how well certain behaviors
are working and what changes they may want to make. It is critical that therapists
monitor any tendency to judge clients’ behavior, but instead to do all that is possible
to get clients to make their own evaluation of their behavior.
Finally, reality therapy makes use of concrete language and simple concepts.
This can erroneously be viewed as a simple approach that does not require a high
level of competence. Because reality therapy is easily understood, it might appear to
be easy to implement. However, the effective practice of reality therapy requires prac-
tice, supervision, and continuous learning (Wubbolding, 2007, 2011a). Competent
reality therapists have a thorough understanding of choice theory and have mas-
tered the art of applying reality therapy procedures to working with diverse clients
with a range of clinical problems.
Self-Reflection and Discussion Questions
1. What do you think of reality therapy’s focus on present behavior and
lack of attention to past events?
2. How could you help your clients to make a self-evaluation to determine
if what they are doing is working for them?
3. If you are working with involuntary clients, how could you use choice
theory and reality therapy principles to increase their cooperation with
the therapy program?
4. What potential do you see in combining reality therapy with some of
the other therapies you have studied? Which theory would you most be
inclined to integrate with reality therapy?
5. Think of a behavior you would like to change. What are some steps you
would take in creating an action plan to get what you want?
Where to Go From Here
Visit CengageBrain.com or watch the DVD for Integrative Counseling: The Case of Ruth and Lec-
turettes, Session 8 (behavioral focus in counseling), to see how i attempt to assist Ruth in
specifying concrete behaviors that she will target for change. in this session i am drawing
heavily from principles of reality therapy in assisting Ruth to develop an action plan to make
the changes she desires.
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C H o i C E T H E o R y / R E A L i T y T H E R A P y 335
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 11, Reality
Therapy, look for these podcasts:
Podcast ACA088, “Reality Therapy, Choice Theory: What’s the Differ-
ence?” by Dr. Robert Wubbolding.
Podcast ACA194, “William Glasser: A Retrospective and Why His Ground-
breaking Work Will Continue to Matter in Professional Counseling,” by
Dr. Robert Wubbolding.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Wubbolding, R. (2007). Reality Therapy
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on demonstrating reality therapy working with
addictions, adults, and children. New video and editorial content is made available
monthly. DVDs relevant to this chapter are available at www.psychotherapy.net and
include the following:
Wubbolding, R. (2000). Reality Therapy (Psychotherapy With the Experts
Series)
Wubbolding, R. (2000). Reality Therapy for Addictions (Brief Therapy for
Addictions Series)
Wubbolding, R. (2002). Reality Therapy With Children (Child Therapy With
the Experts Series)
Wubbolding, R. (2014). Choice Theory/Reality Therapy Demonstration: Couple
Counseling “Elroy and Judy” (Center for Reality Therapy)
The programs offered by William Glasser International are designed to teach
the concepts of choice theory and the practice of reality therapy. More than 7,800
therapists have completed the training in reality therapy and choice theory. The
institute offers a certification process, which starts with a three-day introductory
course known as “basic training” in which participants are involved in discussions,
demonstrations, and role playing. For those wishing to pursue more extensive train-
ing, the institute offers a five-part sequential course of study leading to certifica-
tion in reality therapy, which includes basic training, a basic practicum, advanced
training, an advanced practicum, and a certification week. This 18-month training
program culminates in a Certificate of Completion. For complete information on
this program, contact:
William Glasser International
www.wglasserinternational.org
63727_ch11_rev02.indd 335 31/08/15 12:08 PM
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336 C H A P T E R E L E V E N
The Center for Reality Therapy provides training in the principles of choice the-
ory/reality therapy applied to counseling, coaching, classroom management, addic-
tions, corrections, and families. Robert Wubbolding is a frequent presenter at state,
national, and international conferences. The three-day workshops apply to certifica-
tion in reality therapy.
Center for Reality Therapy
Robert E. Wubbolding, EdD, Director
www.realitytherapywub.com
The International Journal of Choice Theory and Reality Therapy (online journal)
focuses on concepts of internal control psychology, with particular emphasis on
research, development, and practical applications of choice theory and reality ther-
apy principles in various settings. For more information about this journal, contact:
Tom Parish, PhD, Editor
Email: Parishts@gmail.com
Recommended Supplementary Readings
Counseling With Choice Theory: The New Reality Therapy
(Glasser, 2001) represents the author’s latest think-
ing about choice theory and develops the existential
theme that we choose all of our total behaviors. Case
examples demonstrate how choice theory principles
can be applied in helping people establish better
relationships.
Reality Therapy (Wubbolding, 2011a) updates and
extends previous publications on choice theory and
reality therapy. As a part of the APA theories of psy-
chotherapy series, this is a well-written and com-
prehensive overview of reality therapy and choice
theory.
Case Approach to Counseling and Psychotherapy (Corey,
2013) illustrates how prominent reality therapists
Drs. William Glasser and Robert Wubbolding would
counsel Ruth from their different perspectives of
choice theory and reality therapy.
63727_ch11_rev02.indd 336 31/08/15 12:08 PM
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337
12Feminist TherapyCoauthored by Barbara Herlihy and Gerald Corey*
1. Identify the key figures and their
contributions to the development
of feminist therapy.
2. Examine the different forms
of feminist therapy.
3. Differentiate between the six
interrelated principles associated
with feminist therapy.
4. Identify the therapeutic goals that
guide feminist therapists in their
work.
5. Understand the roles of gender
and power in the therapeutic
process.
6. Describe the importance of an
egalitarian relationship and how
collaboration works in the therapy
process.
7. Identify standard feminist therapy
procedures such as therapist self-
disclosure, reframing, relabeling,
gender-role analysis and
intervention, power analysis and
intervention, and social action.
8. Understand the value of
empowerment as a basic strategy.
9. Describe the role of social action
in therapy.
10. Examine the application of
feminist principles to group work.
11. Understand the relationship
between feminist therapy and
multicultural therapy.
12. Identify the key contributions
and main limitations of feminist
therapy.
L e a r n i n g O b j e c t i v e s
*I invited a colleague and friend, Barbara Herlihy, a professor of counselor education at the University
of New Orleans, to coauthor this chapter. We have coauthored two books (Herlihy & Corey, 2015a,
2015b), which seems like a natural basis for collaboration on a project that we both consider valuable.
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338 C H A P T E R T W E LV E
Some Contemporary FeminiSt therapiStS
Feminist therapy does not have a single founder.
Rather, it has been a collective effort by many. We
have selected a few individuals who have made signif-
icant contributions to feminist therapy for inclusion
here, recognizing full well that many other equally
influential scholar-practitioners could have appeared
in this space. Feminist therapy is truly founded on a
theory of inclusion.
Jean Baker Miller / Carol ZerBe enns / oliva M. espín /
laura s. Brown
JEAN BAKER MILLER (1928–2006) was
a clinical professor of psychiatry at Bos-
ton University School of Medicine and
director of the Jean Baker Miller Training
Institute at the Stone Center, Wellesley
College. She wrote Toward a New Psy-
chology of Women (1986) and coauthored
The Healing Connection: How Women Form
Relationships in Therapy and in Life (Miller
& Stiver, 1997) and Women’s Growth in
Connection (Jordan et al., 1991). Miller
collaborated with diverse groups of
scholars and colleagues on the develop-
ment of relational-cultural theory. She
made important contributions toward
expanding this theory and exploring new
applications to complex issues in psycho-
therapy and beyond, including issues of
diversity, social action, and workplace
change.
Co
ur
te
sy
, J
ea
n
Ba
ke
r M
ill
er
T
ra
in
in
g
In
st
itu
te
CAROLYN ZERBE ENNS is Professor of
Psychology and participant in the Women’s
Studies and Ethnic Studies programs at
Cornell College in Mt. Vernon, Iowa. Enns
became interested in feminist therapy while
she was completing her PhD in Counseling
Psychology at the University of California,
Santa Barbara. She devotes much of her
work to exploring the profound impact
feminist theory has on the manner in which
therapists implement therapeutic prac-
tices. Enns most recent efforts are directed
toward articulating the importance of
multicultural feminist therapy, exploring
the practice of feminist therapy around
the world (especially in Japan), and writ-
ing about multicultural feminist pedago-
gies. Two of her recent edited book projects
reflect these priorities: Oxford Handbook of
Feminist Multicultural Counseling Psychology
(co-edited with Elizabeth Nutt Williams,
2013) and Psychological Practice With Women:
Guidelines, Diversity, Empowerment (co-edited
with Joy K. Rice and Roberta L. Nutt, 2015),
which focuses on applying the APA (2007)
Guidelines to diverse groups of women.
Carolyn Zerbe Enns
Co
ur
te
sy
o
f C
ar
ol
yn
Z
er
be
E
nn
s
OLIVA M. ESPÍN is Professor Emerita
in the Department of Women’s Stud-
ies at San Diego State University and
at the California School of Professional
Psychology of Alliant International
University. A native of Cuba, she did
her undergraduate work in psychology
at the Universidad de Costa Rica and
received her PhD from the University of
Florida, specializing in counseling and
therapy with women from different cul-
tures and in Latin American Studies. She
is a pioneer in the theory and practice
of feminist therapy with women from
different cultural backgrounds and
has done extensive research, teaching,
and training on multicultural issues
in psychology. Espín has published on
psychotherapy with Latinas, women
immigrants and refugees, the sexuality
of Latinas, language in therapy with flu-
ent bilinguals, and training clinicians to
work with multicultural populations.
Espín co-edited Refugee Women and Their
Mental Health: Shattered Societies, Shattered
Lives (Cole, Espín, & Rothblum, 1992)
Oliva M. Espín
Co
ur
te
sy
o
f D
r.
O
liv
a
Es
pi
n,
P
ro
fe
ss
or
E
m
er
ita
o
f W
om
en
’s
St
ud
ie
s,
S
an
D
ie
go
S
ta
te
U
ni
ve
rs
ity
Jean Baker Miller
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F E m i n i s T T H E R A P y 339
Introduction
The broad scope of feminist thought goes far beyond gender considerations.
Multicultural and social justice issues are equally relevant to the therapeutic enter-
prise, and, as you will see, feminist counseling/therapy puts intersections of gender
and other social identities, social location, and power at the core of the therapeutic
process. Feminist counseling is built on the premise that it is essential to consider
the social, cultural, and political context that contributes to a person’s problems
in order to understand that person. This perspective has significant implications
for the development of counseling theory and for how practitioners intervene with
diverse client populations.
Feminist psychotherapy is a philosophical orientation that lends itself to an
integration of feminist, multicultural, and social justice concepts with a variety of
psychotherapy approaches (Enns, Williams, & Fassinger, 2013). A central concept
in feminist therapy is the importance of understanding and acknowledging psy-
chological oppression and the constraints imposed by the sociopolitical status to
which women, underrepresented, and marginalized individuals have been relegated.
A feminist perspective offers a unique approach to understanding the roles that
women and men with diverse social identities and experiences have been social-
ized to accept and to bringing this understanding into the therapeutic process.
The socialization of women with multiple social identities inevitably affects their
identity development, self-concept, goals and aspirations, and emotional well-being
(Gilligan, 1982; King, 2013; Turner & Werner-Wilson, 2008). As Natalie Rogers
(1995) has observed, socialization patterns tend to result in women giving away
their power in relationships, often without being aware of it. Feminist counseling
keeps knowledge about gender socialization, sexism, and related “isms” in mind in
the work with all. For some women, ethnicity or race may be experienced as a more
salient identity than gender; for others, identity and the oppression associated with
gender may be fused with racism.
LO1
LAURA S. BROWN is a founding mem-
ber of the Feminist Therapy Institute,
an organization dedicated to the sup-
port of advanced practice in feminist
therapy, and a member of the theory
workgroup at the National Conference
on Education and Training in Feminist
Practice. She has written several books
considered core to feminist practice
in psychotherapy and counseling, and
Subversive Dialogues: Theory in Feminist
Therapy (1994) is considered by many
to be the foundation book address-
ing how theory informs practice in
feminist therapy. Her most recent
book is Feminist Therapy (2010). Brown
has made particular contributions to
thinking about ethics and boundaries
and the complexities of ethical prac-
tice in small communities. Her current
interests include feminist forensic psy-
chology and the application of femi-
nist principles to treatment of trauma
survivors.Laura S. Brown
Co
ur
te
sy
o
f D
r.
La
ur
a
S.
B
ro
w
n
and has written Latina Healers: Lives of Power and Tradi-
tion (1996), Latina Realities: Essays on Healing, Migration,
and Sexuality (1997), and Women Crossing Boundaries:
A Psychology of Immigration and the Transformation of
Sexuality (1999), which is based on a study of women
immigrants from all over the world.
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340 C H A P T E R T W E LV E
The majority of clients in counseling are women, and the majority of psycho-
therapy practitioners at the master’s level are women. However, most theories that
are traditionally taught—including all of the other theories in this book—were
founded by White males from Western (American or European) cultures, with only
Adler taking a pro-feminist stance in early theory development. The need for a the-
ory that evolves from the thinking and experiencing of women seems self-evident.
Theories are developed from the experiences of the “developer,” and feminist theory
is the first therapeutic theory to emerge from a collective effort by women to include
the experiences of multiple voices.
Feminist therapists have challenged male-oriented assumptions regarding what
constitutes a mentally healthy individual. Early feminist therapy efforts focused on
valuing women’s experiences, recognizing political realities, and understanding the
unique issues facing women within a patriarchal system. Contemporary practice
keeps the impact of gender socialization in the forefront when working with clients.
Current feminist practice also emphasizes a diverse approach that includes an under-
standing of multiple oppressions, power, privilege, multicultural competence, social
justice, and the oppression of all marginalized people (American Psychological Asso-
ciation, 2007; Enns & Byars-Winston, 2010). Feminists believe that gender cannot be
considered apart from other identities related to race, ethnicity, socioeconomic class,
age, and sexual orientation. Recent developments relevant to social justice in psy-
chology have led to an integration of key themes of multiculturalism and feminism
(Enns, Williams, & Fassinger, 2013). The contemporary version of feminist therapy
and the multicultural and social justice perspectives to counseling practice have a
great deal in common (Crethar, Torres Rivera, & Nash, 2008). All these approaches
provide a systemic perspective based on understanding the social context of clients’
lives and are aimed toward affecting social change as well as individual change.
Visit CengageBrain.com or watch the video program on Chapter 12, Theory and Practice of
Counseling and Psychotherapy: The Case of Stan and Lecturettes. i suggest that you view the brief
lecture for each chapter prior to reading the chapter.
History and Development
The history of feminist therapy is relatively brief. No single individual can be identi-
fied as the founder of this approach, reflecting a central theme of feminist collabo-
ration. Feminist therapy was developed by several feminist therapists, all of whom
shared the same vision—to improve mental health treatment for women (Evans &
Miller, 2016). The beginnings of feminism (often referred to as the first wave) can be
traced to the late 1800s, but the women’s movement of the 1960s (the second wave)
laid the foundation for the development of feminist therapy. In the 1960s women
began uniting their voices to express their dissatisfaction with the limiting and con-
fining nature of traditional female roles. Consciousness-raising groups, in which
women came together to share their experiences and perceptions, helped individ-
ual women become aware that they were not alone. A sisterhood developed, and
some of the services that evolved from women’s collective desires to improve society
included shelters for battered women, rape crisis centers, and women’s health and
reproductive health centers.
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F E m i n i s T T H E R A P y 341
Believing that personal counseling was a legitimate means to effect change, fem-
inist therapists viewed therapy as a partnership between equals and built mutuality
and collaboration into the therapeutic process. They took the stance that therapy
needed to move away from an intrapsychic perspective on psychopathology (in
which the sources of a woman’s unhappiness reside within her) to a focus on under-
standing the social, political, and cultural forces in society that damage, oppress,
and constrain girls and women, as well as boys and men.
Gilligan’s (1982) work on the development of a morality of care in women, and
the work of Miller (1986) and the Stone Center scholars in developing the self-in-
relation model (now called the “relational-cultural” model) were influential in the
evolution of a feminist personality theory. New theories emerged that honored the
relational and cooperative dimensions of women’s experiencing (Enns, 1991, 2000,
2004). Feminist therapists began to formally examine the relationship of feminist
theory to traditional psychotherapy systems, and integrations with various existing
systems were proposed. Some counselors identified themselves as psychoanalytic
feminist therapists or as Adlerian-feminist counselors, to mention just two possible
integrations.
By the 1980s feminist group therapy had changed dramatically, becoming
more diverse as it focused increasingly on specific problems and issues such as body
image, abusive relationships, eating disorders, incest, and other forms of sexual
abuse (Enns, 1993). The feminist philosophies that guided the practice of therapy
also became more diverse.
The variety within feminist theories provides a range of different but overlap-
ping perspectives from which to work (Enns & Sinacore, 2001). Brown (2010) defines
feminist therapy as a postmodern, technically integrative approach that emphasizes
the analysis of gender, power, and social location as strategies for facilitating change.
Feminist therapists, both male and female, believe that understanding and con-
fronting gender-role stereotypes and power are central to therapeutic practice and
that addressing a client’s problems requires adopting a sociocultural perspective:
namely, understanding the impact of the society and culture in which a client lives.
Key Concepts
Constructs of Feminist Theory
Worell and Remer (2003) describe the constructs of feminist theory as being
gender fair, flexible–multicultural, interactionist, and life-span-oriented. gender-
fair approaches explain differences in the behavior of women and men in terms
of socialization processes rather than on the basis of our “innate” natures, thus
avoiding dichotomized stereotypes in social roles and interpersonal behavior. A
flexible–multicultural perspective uses concepts and strategies that apply equally
to individuals and groups regardless of age, race, culture, gender, ability, class, or
sexual orientation. The interactionist view contains concepts specific to the think-
ing, feeling, and behaving dimensions of human experience and accounts for con-
textual and environmental factors. A life-span perspective assumes that human
development is a lifelong process and that personality and behavioral changes can
occur at any time rather than being fixed during early childhood.
LO2
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342 C H A P T E R T W E LV E
Feminist Perspective on Personality Development
Feminist therapists emphasize that societal gender-role expectations profoundly
influence a person’s identity from the moment of birth, or even prior to birth once
the sex is identified, and become deeply ingrained in adult personality. Gilligan
(1977) recognized that theories of moral development were based almost exclusively
on research with White males. Gilligan was the first to recognize that male develop-
ment was presented as the norm and that development of women, though different,
was judged by male norms. As a result of her studies on women’s moral and psy-
chosocial development, Gilligan came to believe women’s sense of self and morality
is based in issues of responsibility and care for other people and is embedded in a
cultural context. She posited that the concepts of connectedness and interdepen-
dence—virtually ignored in male-dominated developmental theories—are central to
women’s development.
Kaschak (1992) used the term engendered lives to describe her belief that gender
is the organizing principle in people’s lives. She has studied the role gender plays in
shaping the identities of females and males and believes the masculine defines the
feminine. In most cultures what is considered attractive in a female is defined by men
in that culture. For instance, because men pay great attention to women’s bodies in
Western society, women’s appearance is given tremendous importance. It is easy to
see how this perspective gets reified in both eating disorders and various forms of
depression. Men, as the dominant group, also define and determine the roles that
women play. Because women occupy a subordinate position, to survive and thrive in
society they must be able to interpret the needs and behaviors of the dominant group.
To that end, women have developed “women’s intuition” and have included in their
gender schema an internalized belief that women are less important than men.
Females are raised in a culture grounded in sexism, and understanding and
acknowledging internalized oppression is central in feminist work. Like all marginal-
ized groups, women are bicultural. They share their own culture with other women and
also have a deep understanding of the male culture that perpetuates patriarchy. Men,
on the other hand, do not have to understand the culture of women in order to survive.
Feminist practitioners remind us that traditional gender stereotypes of women
are still prevalent in cultures throughout the world. They teach their clients that
uncritical acceptance of traditional roles can greatly restrict their range of freedom.
Today many women and men are resisting being so narrowly defined. Women and
men in therapy learn that, if they choose to, they can experience mutual behavioral
characteristics such as accepting themselves as being interdependent, giving to oth-
ers, being open to receiving, thinking and feeling, and being tender and strong.
Rather than being cemented to a single behavioral style, women and men who reject
traditional roles are saying that they are entitled to express the complex range of
characteristics that are appropriate for different situations and that they are open to
their vulnerability as human beings.
Relational-Cultural Theory
Most models of human growth and development emphasize a struggle toward inde-
pendence and autonomy, but feminists recognize that many women are searching for
a connectedness with others as well as possibilities for autonomy. In feminist therapy,
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F E m i n i s T T H E R A P y 343
women’s relational qualities are seen as strengths and as pathways for healthy growth
and development, instead of being identified as weaknesses or defects.
The founding scholars of relational-cultural theory (rct) have elaborated
on the vital role that relationships and connectedness with others play in the lives
of women (Jordan, 2010; Jordan et al,, 1991; Miller, 1986, 1991; Miller et al., 1999;
Miller & Stiver, 1997; Surrey, 1991; Trepal, 2010). These scholars suggest that a
woman’s sense of identity and self-concept develop in the context of relationships.
They describe a process of relational movement in which women move through con-
nections, disconnections, and enhanced transformative relationships throughout
their lives (Comstock et al., 2008). Therapists emphasize the qualities of authenticity
and transparency that contribute to the flow of the relationship; being empathically
present with the suffering of the client is at the core of treatment (Surrey & Jordan,
2012). Therapists aim to lessen the suffering caused by disconnection and isola-
tion, increase clients’ capacity for relational resilience, develop mutual empathy and
mutual empowerment, and foster social justice (Jordan, 2010). According to Jordan,
through mutual empathy people find that they can bring more of themselves into
relationships, and in this process they become more open to learning and change.
Jordan notes that RCT is not about helping people adjust to conditions; rather, this
therapy is about enhancing the client’s desire for connection and building networks
and community. Finding growth-fostering relationships leads to a greater sense of
involvement in the world and in the well-being of others. Relational-cultural therapy
practitioners emphasize mutual empathy and deep respect for the client, understand
how disconnections affect the individual, and create a therapeutic relationship that
is healing (Surrey & Jordan, 2012). For empathy to result in healing and decreased
isolation, clients must be able to feel the therapist’s empathic response. As you will
see, many of the techniques of feminist therapy foster mutuality, equality, relational
capacities, and growth in connection.
Principles of Feminist Therapy
A number of feminist writers have articulated the interrelated and overlap-
ping core principles that form the foundation for the practice of feminist therapy:
1. The personal is political and critical consciousness. This principle is based
on the assumption that the personal or individual problems individu-
als bring to counseling originate in a political and social context. For
females this is often a context of marginalization, oppression, subordi-
nation, and stereotyping. Acknowledgment of the political and societal
impact on an individual’s life is perhaps the most fundamental tenet
that lies at the core of feminist therapy.
2. Commitment to social change. Feminist therapies aim not only for individ-
ual change but also for societal change. A distinctive feature of feminist
therapy is the assumption that direct action for social change is one of
the responsibilities of therapists. Counselors who work with women
survivors of sexual violence also do social justice work to educate and
transform the rape culture in which we live. It is important for clients
who engage in the therapy process to recognize how some of their
social identities may grant them unearned privileges and advantages as
LO3
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344 C H A P T E R T W E LV E
well as to recognize how they have suffered from oppression as mem-
bers of a subordinate group and that they can join with others to right
these wrongs. Counselors cannot help clients recognize privilege and
oppression if they do not understand how these identities have affected
their own lives. The goal is to advance a different vision of societal orga-
nization that frees both women and men from the constraints imposed
by gender-role and social class-related expectations. This vision of
counseling, which moves away from the traditional focus on change
from within the individual out into the realm of social activism and
societal change, distinguishes feminist therapy from other historically
accepted approaches.
3. Women’s and girls’ voices and ways of knowing, as well as the voices of others
who have experienced marginalization and oppression, are valued and their
experiences are honored. Traditional therapies operate on androcentric,
heterosexist norms embedded in White middle-class heterosexual val-
ues and describe women and other marginalized individuals as deviant.
Feminist therapists replace patriarchal and other forms of “objective
truth” with feminist and social justice consciousness and encourage
clients to use their personal experience as a touchstone for determin-
ing what is “reality.” Shifting women’s experiences from being ignored
and devalued to being sought after and valued is strongly encouraged
by feminist therapists (Evans & Miller, 2016). When women’s voices
are acknowledged as authoritative, invaluable sources of knowledge,
women and other marginalized people can contribute to profound
change in the body politic of society.
4. The counseling relationship is egalitarian. Attention to power is central in
feminist therapy. The egalitarian relationship, which is marked by
authenticity, mutuality, and respect, is at the core of feminist therapy
(Pusateri & Headley, 2015). Feminist therapists recognize that there is a
power imbalance in the therapeutic relationship, so they strive to shift
power and privilege to the voices and experiences of clients and away
from themselves. An open discussion of power and role differences in
the therapeutic relationship helps clients to understand how power
dynamics influence both counseling and other relationships and also
invites a dialogue about ways to reduce power differentials (Enns, 2004;
Evans & Miller, 2016).
5. A focus on strengths and a reformulated definition of psychological distress.
Feminist therapy has a “conflicted and ambivalent relationship” with
diagnostic labeling and the “disease model” of mental illness (Brown,
2010, p. 50). Psychological distress is reframed, not as disease but as a
communication about unjust systems. When contextual variables are
considered, symptoms can be reframed as survival strategies. Feminist
therapists talk about problems in the context of living and coping
skills rather than pathology (Enns, 2004; Worell & Remer, 2003). For
example, a client who is a survivor of childhood sexual abuse may pres-
ent with dissociation, which is understood as a way of coping in order
to survive as a child.
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F E m i n i s T T H E R A P y 345
6. All types of oppression are recognized along with the connections among them.
Clients can best be understood in the context of their sociocultural
environments. Feminist practitioners acknowledge that social and
political inequities have a negative effect on all people. Feminist
therapists work to help individuals make changes in their lives, but
they also are committed to working toward social change that will
liberate all members of society from stereotyping, marginalization,
and oppression. Diverse sources of oppression, not simply gender,
are identified and interactively explored as a basis for understanding
the concerns that clients bring to therapy. Framing clients’ issues
within a cultural context leads to empowerment, which can be fully
realized only through social change (Evans & Miller, 2016; Worell &
Remer, 2003).
The Therapeutic Process
Therapeutic Goals
According to Enns (2004), goals of feminist therapy include empower-
ment, valuing and affirming diversity, striving for change rather than adjust-
ment, equality, balancing independence and interdependence, social change, and
self-nurturance. A key goal of feminist therapy is to assist individuals in viewing
themselves as active agents on their own behalf and on behalf of others. At the
individual level, feminist and other social justice therapists work to help indi-
viduals recognize, claim, and embrace their personal power. A related goal is to
help individuals come together to strengthen collective power. Through empow-
erment, clients are able to free themselves from the constraints of their gender-
role socialization and other internalized limitations and to challenge ongoing
institutional oppression.
According to Worell and Remer (2003), feminist therapists help clients:
�� Become aware of their own gender-role socialization process
�� Identify their internalized messages of oppression and replace them
with more self-enhancing beliefs
�� Understand how sexist and oppressive societal beliefs and practices
influence them in negative ways
�� Acquire skills to bring about change in the environment
�� Restructure institutions to rid them of discriminatory practices
�� Develop a wide range of behaviors that are freely chosen
�� Evaluate the impact of social factors on their lives
�� Develop a sense of personal and social power
�� Recognize the power of relationships and connectedness
�� Trust their own experience and their intuition
Feminist therapists aim to empower all people to create a world of equality that
is reflected at individual, interpersonal, institutional, national, and global levels
(Enns & Byars-Winston, 2010). Making oppression transparent is the first step,
but the ultimate goal is to replace sexism and other forms of discrimination and
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346 C H A P T E R T W E LV E
oppression with empowerment for all marginalized groups (Brabeck & Brabeck,
2013; Worell & Remer, 2003). Feminist counseling strives for transformation for
both the individual client and society as a whole.
Therapist’s Function and Role
Many therapeutic orientations articulate a belief in a therapeutic milieu that is free
of biased assumptions about women and other oppressed and marginalized groups.
Therapeutic orientations and counseling theories, on the whole, assert that all cli-
ents should be treated with respect. The difference between these approaches and
feminist therapy is that feminist therapy is based firmly in feminist philosophy that
centralizes the sociocultural context of clients’ mental health status.
Theories and techniques are based on the lives and experiences of individuals
(lived experiences) as well as research supporting gender and other inequities (Evans,
Kincade, & Seem, 2011). Feminist therapists have shared assumptions about ther-
apy, but they come from diverse backgrounds and have various lived experiences
that may affect how techniques are applied as well as how clients are conceptualized.
In Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 10), three femi-
nist therapists (Drs. Evans, Kincade, and Seem) team up to demonstrate a variety of
feminist interventions in their work with Ruth. They also conceptualize the case of
Ruth from a feminist therapy perspective.
Feminist practitioners have integrated feminism, multiculturalism, and other
social justice perspectives into their approach to therapy and into their lives. Their
actions and beliefs and their personal and professional lives are congruent. They are
committed to monitoring their own biases and distortions, especially the social and
cultural dimensions of women’s experiences. Feminist and social justice therapists
are also committed to understanding oppression in all its forms—including but not
limited to sexism, racism, heterosexism—and they consider the impact of oppres-
sion and discrimination on psychological well-being. They value being emotionally
present for their clients, being willing to share themselves during the therapy hour,
modeling proactive behaviors, and being committed to their own consciousness-
raising process (Evans, Kincade, Marbley & Seem, 2005).
Feminists share common ground with Adlerian therapists in their empha-
sis on social equality and social interest, and with existential therapists who
emphasize therapy as a shared journey, one that is life changing for both client
and therapist, and with their basic trust in the client’s ability to move forward
in a positive and constructive manner (Bitter, Robertson, Healey, & Cole, 2009).
Feminist therapists believe the therapeutic relationship should be a nonhierar-
chical, person-to-person relationship, and they aim to empower clients to live
according to their own values and to rely on an internal (rather than external
or societal) locus of control in determining what is right for them. Like person-
centered therapists, feminist therapists convey their genuineness and strive for
mutual empathy between client and therapist. Unlike person-centered therapists,
however, feminist therapists do not see the therapeutic relationship alone as
being sufficient to produce change. Insight, introspection, and self-awareness are
springboards to action.
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F E m i n i s T T H E R A P y 347
Feminist therapists share with postmodern therapists (see Chapter 13) an
emphasis on the politics and power relationships in the therapy process and a con-
cern about power relations in the world in general. Both feminist and postmodern
thought asserts that psychotherapists must not replicate societal power imbalances
or foster dependency in the client. Rather, therapist and client take active and equal
roles, working together to determine goals and procedures. A common denomina-
tor of both feminist and postmodern approaches is the avoidance of assuming a
therapist role of all-knowing expert.
Client’s Experience in Therapy
Clients are partners in the therapeutic process. It is important that clients
tell their stories and give voice to their experiencing. Clients determine what they
want from therapy and are the experts on their own lives. A male client, for example,
may choose to explore ways in which he has been both limited and privileged by his
gender-role socialization. In the safe environment of the therapeutic sessions, he
may be able to fully experience emotions of sadness, tenderness, uncertainty, and
empathy. As he transfers these ways of being to daily living, he may find that rela-
tionships change in his family, his social world, and at work.
Feminist practitioners recognize that gender is only one identity and source of
marginalization and oppression, and they value the complex ways in which multiple
identities shape a person’s concerns and preferences. Worell and Remer (2003) write
that clients acquire a new way of looking at and responding to their world. They add
that the shared journey of empowerment can be both frightening and exciting—for
both client and therapist. Clients need to be prepared for major shifts in their way
of viewing the world around them, changes in the way they perceive themselves, and
transformed interpersonal relationships.
Relationship Between Therapist and Client
In feminist therapy, the very structure of the client–therapist relationship
models how to identify and use power responsibly. A defining theme of the client–
counselor relationship is the inclusion of clients in both the assessment and the treat-
ment process, keeping the therapeutic relationship as egalitarian as possible. Feminist
therapists clearly state their values during the informed consent process to reduce the
chance of value imposition. This allows clients to make a choice regarding whether or
not to work with the therapist. It also is a step in demystifying the process.
As mentioned, although there is an inherent power differential in the therapy
relationship, feminist therapists are aware of ways they might abuse their own power
in the therapy relationship, such as by diagnosing unnecessarily, or without the cli-
ent’s knowledge and input, by interpreting or giving advice, by staying aloof behind
an “expert” role, or by discounting the impact the power imbalance between thera-
pist and client has on the relationship. They work to demystify the counseling rela-
tionship by sharing with the client their own perceptions about what is going on in
the relationship, by conveying clearly that the client is the expert on her or his life,
and by using appropriate self-disclosure.
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348 C H A P T E R T W E LV E
Application: Therapeutic Techniques and Procedures
The Role of Assessment and Diagnosis
Feminist therapists have been sharply critical of past versions of the DSM
classification system (DSM- III through DSM -IV-TR), as well as of the current DSM-5
edition (Marecek & Gavey, 2013). This critique is based on research indicating that
gender, culture, and race may influence assessment of clients’ symptoms (e.g., Enns,
2000; Eriksen & Kress, 2005). To the degree that conceptualization and assessment
are influenced by subtle forms of sexism, racism, ethnocentrism, heterosexism, age-
ism, or classism, it is extremely difficult to arrive at a meaningful conceptualization,
assessment, or diagnosis.
From the perspective of feminist therapy, diagnoses are based on the dominant
culture’s view of normalcy and therefore cannot account for cultural differences
(Pusateri & Headley, 2015). Feminist therapists refer to distress rather than psycho-
pathology (Brown, 2010), and they use diagnostic labels quite carefully, if at all. They
believe diagnostic labels are severely limiting for these reasons: (1) they focus on the
individual’s symptoms and not the social factors that cause distress and dysfunc-
tional behavior; (2) they are part of a system developed mainly within psychiatry,
an institution that reinforces dominant cultural norms and may become an instru-
ment of oppression; (3) they may reflect the inappropriate application of power in
the therapeutic relationship; (4) they can lead to an overemphasis on individual
solutions rather than social change; and (5) they have the potential to dehumanize
the client through labeling.
Feminist therapists believe that external factors and contextual factors are as
important as internal dynamics in understanding the client’s presenting problems
(Evans & Miller, 2016). The feminist approach emphasizes that many symptoms can
be understood as coping or survival strategies rather than as evidence of pathology
(Bitter, 2008; Worell & Remer, 2003). Due to the cultural and gender limitations of
diagnoses, Eriksen and Kress (2005) encourage therapists “to be tentative in diag-
nosing those from diverse backgrounds, and to, as a part of a more egalitarian rela-
tionship, co-construct an understanding of the problem with the client, rather than
imposing a diagnosis on the client” (p. 104). Reframing symptoms as resistance to
oppression and as coping skills or strategies for survival and shifting the etiology
of the problem to the environment avoids “blaming the victim” for her or his prob-
lems. Assessment is viewed as an ongoing process between client and therapist and
is connected to treatment interventions. In the feminist therapy process, diagnosis
of distress becomes secondary to identification and assessment of strengths, skills,
and resources (Brown, 2010).
The emphasis of feminist therapy is on wellness rather than disease, resilience
rather than deficits, and a celebration of diverse strengths (Brabeck & Brabeck,
2013). Diagnosis, when used, results from a shared dialogue between client and ther-
apist. The counselor is careful to review with the client any implications of assigning
a diagnosis so the client can make an informed choice, and discussion focuses on
helping the client understand the role of socialization and culture in the etiology of
these problems.
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F E m i n i s T T H E R A P y 349
Techniques and Strategies
Feminist therapy does not prescribe any particular set of interventions and tailors
interventions to clients’ strengths with the goal of empowering clients while evok-
ing their feminist consciousness (Brown, 2010). Nonetheless, they have developed
several unique techniques and have borrowed others from traditional approaches.
Particularly important are consciousness-raising techniques that help women dif-
ferentiate between what they have been taught is socially acceptable or desirable
and what is actually healthy for them. Some of the techniques described by Worell
and Remer (2003), Enns (1993, 2004), Evans, Kincade, and Seem (2011) and Evans and
Miller (2016) are discussed in this section, using the case example of Alma to illus-
trate how these techniques might be applied.
Alma, age 22, comes to counseling reporting general anxiety about a new job she
began a month ago. She states that she has struggled with depression off and on
throughout her life because of bullying as a child and rejection from much of her
family after coming out as a lesbian at age 14. Alma identifies as Dominican and
continues to struggle with the loss of her place within her family of origin. She now
believes coming out was a selfish mistake and is trying to make amends by keeping
her feelings regarding her sexual and affectional orientation hidden. Due in part to
past experiences, she is worried that if she comes out to her coworkers the company
might find a reason to fire her. Alma says, “I would like to cut my hair short again
because it is more manageable and I also prefer to wear what is considered to be
more masculine clothing, but I am worried this will cause people at work to ques-
tion my femininity. I really like my job, and I worked very hard to get it. I am afraid
if I show them who I really am, they won’t want me there anymore.”
Empowerment At the heart of feminist strategies is the goal of empowering
the client. Feminist therapists work in an egalitarian manner and use empowerment
strategies that are tailored to each client (Brown, 2010; Evans et al,, 2011). Alma’s
therapist will pay careful attention to informed consent issues, discussing ways Alma
can get the most from the therapy session, clarifying expectations, identifying goals,
and working toward a contract that will guide the therapeutic process.
Informed consent offers a place to begin a relationship that is egalitarian and col-
laborative. By explaining how therapy works and enlisting Alma as an active partner
in the therapeutic venture, the therapy process is demystified and Alma becomes an
equal participant. Alma will learn that she is in charge of the direction, length, and
procedures of her therapy. Alma’s therapist might ask her, “What is the most pow-
erful thing you could do for yourself right now?” The intent of this question is to
“interrupt the trance of powerlessness” by inviting Alma to notice how power is actu-
ally available to her (Brown, 2010, p. 35). Given Alma’s cultural background, it may be
particularly important to address power within the therapeutic relationship because
Alma may view the therapist as an expert who holds the answers she is seeking.
Self-Disclosure Feminist therapists use therapeutic self-disclosure in the best
interests of the client to equalize the client–therapist relationship, to provide
modeling, to normalize women’s collective experiences, to empower clients, and to
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350 C H A P T E R T W E LV E
establish informed consent. The counselor engages in self-disclosure only when it
is judged to be therapeutically helpful to the client. For example, Alma’s therapist
may briefly disclose her own difficulties in relating to members of her family of
origin, acknowledging that at times hiding information seems important in order to
keep the peace. The counselor might share how she decides when and when not to
be open about her personal life. The counselor could then discuss with Alma ways
in which they have both experienced cultural and social pressures to conform to a
hetero-normative ideal. Alma benefits from this modeling by a woman who does not
meet society’s expectations for female behavior and appearance but is comfortable
with the image she has developed and how it has worked for her, not against her. The
counselor’s disclosure would happen over time, for it is crucial that the counselor does
not overshadow the client’s time to explore the concerns that bring her to therapy.
Self-disclosure goes beyond sharing information and experiences; it also involves
the quality of presence the therapist brings to the therapeutic sessions. Effective ther-
apist self-disclosure is grounded in authenticity and a sense of mutuality. The thera-
pist explains to Alma the therapeutic interventions that are likely to be employed.
Alma, as an informed consumer, will be involved in evaluating how well these strate-
gies are working and the degree to which her personal goals in therapy are being met.
Gender-Role or Social Identity Analysis A hallmark of feminist therapy, gender-
role analysis assists clients in identifying the impact that their own gender-role
socialization has played in shaping their values, thoughts, and behaviors (Evans
& Miller, 2016). Some feminist therapists prefer the term “social identity analysis”
because it reflects the importance of assessing all relevant aspects of a client’s identity,
including multiple memberships in both socially disempowered and privileged
groups. For example, Alma identifies as a female, a lesbian, and a Dominican—all
marginalized identities within the dominant culture. Social identity and gender-role
analysis begins with clients identifying the societal messages they received about
how women and men should be and act as well as how these messages interact with
other important aspects of identity (Remer, 2013). The therapist begins by asking
Alma to identify messages she has received related to sexuality, race/ethnicity, and
appearance from her culture, society, her peers, the media, and her family. The
therapist talks about how body image expectations differ between females and males
in our culture and how they may differ in other cultures. The therapist explains
how expectations related to appearance could intersect with beliefs about what it
means to be gay or straight in Alma’s culture, family, and society as it relates to her
working environment. As Alma identifies the messages playing in her head and the
voices behind those messages, she is living with a mindfulness of her internalized
oppression. Alma decides what messages she would prefer to have in her mind and
keeps an open awareness when the discounting messages play in her head. The goal
is for Alma to adopt realistic and affirming internal messages.
Gender-Role Intervention Using this technique, the therapist responds to Alma’s
concern by placing it in the context of society’s role expectations for women. The
aim is to provide Alma with insight into the ways social issues are affecting her.
Alma’s therapist responds to her statement with, “Our society really focuses on
sometimes unrealistic beauty ideals with females. The media bombards girls and
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F E m i n i s T T H E R A P y 351
women with the message that they must be thin, have long straight hair, and wear
attractive clothing. The message is so ingrained that many girls are struggling with
self-esteem issues related to their appearance as early as elementary school to avoid
being bullied or to fit in.” By placing Alma’s concern in the context of societal
expectations, the therapist gives Alma insight into how these expectations have
affected her psychological condition and have contributed to her feeling depressed
and anxious about judgment from others. The therapist’s statement also paves
the way for Alma to think more positively about her unity with other women and
even to think about how she might contribute as a role model for girls and young
women in the future. Alma is increasing her awareness of the strong role media play
in perpetuating oversexualized images of women and how those images affect her
self-esteem. Alma may decide to begin a dialogue with other women to discuss ways
to create significant change.
Power Analysis Power analysis refers to the range of methods aimed at helping
clients understand how unequal access to power and resources can influence
personal realities. Together therapists and clients analyze how various forms of
power in the dominant and subordinate group limit self-definition and well-being
(Enns, 2004; Pusateri & Headley, 2015). Alma will become aware of the power
difference between women and men as well as the power differences associated with
sexual orientation and ethnic status in our society. Specific issues related to Alma’s
cultural perspective also are explored. The power analysis may focus on helping
Alma identify alternate kinds of power she may exercise and learn how to challenge
the gender-role messages that prohibit the exercise of that kind of power. Alma
choreographs the changes she wants to make in her life. Interventions are aimed at
helping Alma learn to appreciate herself as she is, regain her self-confidence based
on the personality attributes she possesses, and set goals that will be fulfilling to her
within the context of her cultural values.
Bibliotherapy Nonfiction books, psychology and counseling textbooks,
autobiographies, self-help books, educational videos, films, and even novels can
all be used as bibliotherapy resources. Reading about feminist and multicultural
perspectives on common issues in women’s lives (incest, rape, domestic violence,
and sexual harassment) may challenge a woman’s tendency to blame herself for
these problems (Remer, 2013). The therapist describes a number of books that
address issues of relevance to Alma, and she selects one to read over the next few
weeks. Providing Alma with reading material increases knowledge and decreases the
power difference between Alma and her therapist. Reading can supplement what is
learned in the therapy sessions, and Alma can enhance her therapy by exploring her
reactions to what she is reading. For women with diverse social identities, books,
biographies, and memoirs written by women with similar or related identities can
provide concrete examples of empowerment and can facilitate growth.
Assertiveness Training By teaching and promoting assertive behavior, women
become aware of their interpersonal rights, transcend stereotypical gender roles,
change negative beliefs, and implement changes in their daily life. Alma may learn how
sexism has contributed to keeping females passive. For example, a woman behaving
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352 C H A P T E R T W E LV E
in an assertive way is often labeled “aggressive,” but similar behavior in a man may
be viewed as “assertive.” Therapist and client consider what is culturally appropriate,
and the client decides when and how to be assertive, balancing the potential costs
and benefits of assertiveness within the ecological context relevant to the client. The
therapist helps Alma evaluate and anticipate the consequences of behaving assertively,
which might range from criticism to actually getting what she wants.
Through learning and practicing assertive behaviors and communication, Alma
may increase her own power, which will ameliorate her depression and anxiety. Alma
learns that it is her right to ask for what she wants and needs in the workplace.
Reframing and Relabeling Like bibliotherapy, therapist self-disclosure, and
assertiveness training, reframing is not unique to feminist therapy. However,
reframing is applied uniquely in feminist therapy. reframing includes a shift
from placing the problem internally and “blaming the victim” to a consideration
of social factors in the environment that contribute to a client’s problem. Rather
than dwelling exclusively on intrapsychic factors, the focus is on examining societal
or political dimensions. Alma may come to understand that her depression and
anxiety are linked to social pressures to behave within hetero-normative gender-
role expectations and to develop an appearance that matches these culturally and
societally prescribed ideals.
relabeling is an intervention that changes the label or evaluation applied to
some behavioral characteristic. Alma can change certain labels she has attached to
herself, such as being inadequate or socially unwanted because she does not conform
to ideals commonly associated with femininity. An example might be that Alma is
encouraged to talk about herself as a strong and healthy woman rather than as being
“selfish” or too “masculine.”
Social Action Social action, or social activism, is an essential quality of
feminist counseling (Enns et al., 2013; Evans et al., 2011; Evans & Miller, 2016).
As clients become more grounded in their understanding of feminism, therapists
may suggest that clients become involved in activities such as volunteering at a rape
crisis center, lobbying lawmakers, or providing community education about gender
issues. Participating in such activities can empower clients and help them see the
link between their personal experiences and the sociopolitical context in which they
live. Alma might decide to join and participate in organizations that are working to
change societal stereotypes about female beauty expectations for women or social
groups that affirm people who identify with a variety of sexual and affectional
orientations. Participating in social action can increase self-esteem and a sense of
personal power.
Group Work Feminist therapists often encourage their clients to make the
transition from individual therapy to a group format such as joining a support group
or a political action group as soon as this is realistic (Herlihy & McCollum, 2011).
Although these groups are as diverse as the women who comprise them, they share
a common denominator emphasizing support for the experience of women. The
literature reveals that women who join these groups eventually realize that they are
not alone and gain validation for their experiences by participating in the group. These
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F E m i n i s T T H E R A P y 353
groups can provide women with a social network, decrease feelings of isolation, create
an environment that encourages sharing of experiences, and help women realize that
they are not alone in their experiences (Eriksen & Kress, 2005). Groups provide a place
where women are valued and affirmed and where they can share and begin to critically
explore the messages they have internalized about their self-worth and their place in
society. The self-disclosures of both the members and the leader foster deeper self-
exploration, a sense of universality, and increased levels of cohesion. Members learn to
use power effectively by providing support to one another, practicing behavioral skills,
considering social/political actions, and by taking interpersonal risks in a safe setting
(Enns, 2004). Through their group participation, women learn that their individual
experiences are frequently rooted in problems within the system. Participation in a
group experience can inspire women to take up some form of social action. Indeed, a
form of homework can be to carry out what women are learning in the group to bring
about changes in their lives outside of the group.
Alma and her therapist will likely discuss the possibility of Alma joining a women’s
support group, a gay-straight alliance, or another type of group as a part of the process
of terminating individual therapy. Participating in a group can enhance Alma’s sense
of community. She will witness the journey of personal and collective transformation
and growth as she adds to her group of supporters, encouragers, and teachers. Other
women can provide her with nurturance and support, and Alma will have the chance
to be significant to other women as they engage in their healing process.
The Role of Men in Feminist Therapy
Men can be feminist therapists, and feminist therapy can be practiced with male cli-
ents. It is an erroneous perception that feminist therapy is conducted only by women
and for women, or that feminist therapy is anti-men because it is pro-women (Evans
et al., 2011; Herlihy & McCollum, 2011). Although the original feminist therapists
were all women, men have now joined their ranks. Male feminist therapists are
willing to understand and “own” their male privilege, confront sexist behavior in
themselves and others, redefine masculinity and femininity according to other than
traditional values, work toward establishing egalitarian relationships, and actively
engage in and support women’s efforts to create a just society.
The principles and practices of feminist psychotherapy are useful in working with
male clients, individuals from diverse racial and cultural backgrounds, and people
who are committed to addressing social justice issues in counseling practice (Enns,
2004; Worell & Remer, 2003). Social mandates about masculinity such as restric-
tive emotionality, overvaluing power and control, the sexualization of emotion, and
obsession with achievement can be limiting to males (Englar-Carlson, 2014).
Female counselors who work with male clients have an opportunity to create an
accepting, authentic, and safe climate in which men can reflect on their needs, choices,
past and present pain, and hopes for their future. By using relational-cultural theory,
female counselors provide a forum for men to consider the contexts that helped
shape them (Duffey & Haberstroh, 2014). Any presenting issue of male clients can be
dealt with from a feminist perspective. For a comprehensive treatment of counseling
men in specialized modalities and settings, intersections of identity, and specialized
populations and concerns, see Englar-Carlson, Evans, and Duffey (2014).
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354 C H A P T E R T W E LV E
Feminist Therapy From a Multicultural
and Social Justice Perspective
Strengths From a Diversity Perspective
Of all the theoretical approaches to counseling and psychotherapy in this
book, feminist therapy has the most in common with the multicultural and social
justice perspectives. Historically, multicultural approaches evolved in response to
societal oppression, discrimination, and marginalization faced by people of color.
Over time, the multicultural perspective has made counseling more inclusive.
Contemporary counselors who infuse their work with a multicultural perspective
address a wide variety of inequities that limit full participation in society. The social
justice perspective in counseling aims to empower the individual as well as to con-
front injustice and inequality in society.
Although multicultural, feminist, and social justice counseling have been viewed
as disparate models, they have many common threads (Crethar et al., 2008). All three
approaches emphasize the need to promote social, political, and environmental
changes within the counseling context. Practitioners of all three perspectives strive
to create an egalitarian relationship in which counselor and client co-construct the
client’s problems from a contextual perspective and collaborate in setting goals and
choosing strategies. All three approaches reject the “disease model” of psychopa-
thology; they view clients’ problems as symptoms of their experiences of living in an
unjust society rather than as having an intrapsychic origin.
Feminist therapy’s primary tenet, “the personal is also the political,” has been
embraced by the multicultural and social justice perspectives. None of the perspec-
tives rests solely on individual change; they all emphasize direct action for social
change as a part of the role of therapists. Williams and Enns (2013) encourage ther-
apists to become activists by making a commitment to social change: “Make the
political personal—understand your own history and roots and work to own your
own privilege. Perhaps most important, you should choose to do social justice work
for you” (p. 488).
Culture encompasses the sociopolitical reality of people’s lives, including
how the privileged dominant group (in Western societies: males, Whites, Chris-
tians, heterosexuals, and the rich) treats those who are different from them.
Feminist therapists believe psychotherapy is inextricably bound to culture, and,
increasingly, they are being joined by thoughtful leaders in the field of counseling
practice.
Culturally competent feminist therapists look for ways to work within the con-
text of the client’s culture by exploring consequences and alternatives. They appre-
ciate the complexities involved in changing within one’s culture, but do not view
culture as sacrosanct (Worell & Remer, 2003). It is important to understand and
respect diverse cultures, but most cultural contexts have both positive and toxic
aspects, and the toxic aspects that oppress and marginalize groups of people need to
be explored. Feminist therapists are committed to taking a critical look at cultural
beliefs and practices that discriminate against, subordinate, and restrict the poten-
tial of groups of individuals.
LO11
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F E m i n i s T T H E R A P y 355
Shortcomings From a Diversity Perspective
Feminist practitioners advocate for change in the social structure, especially in the areas
of inequality, power in relationships, the right to self-determination, freedom to pursue
a career outside or inside the home, and the right to an education. This agenda could
pose some problems when working with women who do not share these beliefs. Remer
(2013) acknowledges that if therapists do not fully understand and respect the cultural
values of clients from diverse groups, they run the risk of imposing their own values.
Remer claims “a potential danger inherent in feminist counseling is that counselors’
values will too strongly influence clients or will conflict with clients’ values” (p. 404).
Being aware of the cultural context is especially important when feminist thera-
pists work with women from cultures that endorse culturally prescribed roles that
keep women in a subservient place or that are grounded in patriarchy. Consider this
scenario. You are a feminist therapist working with a Vietnamese woman who is
struggling to find a way to be true to her culture and also to follow her own educa-
tional and career aspirations. Your client is a student in a helping profession who is
being subjected to extreme pressure from her father to return home and take care of
her family. Although she wants to complete a degree and eventually help others in
the Vietnamese community, she feels a great deal of guilt when she considers “self-
ishly” pursuing her education when her family at home needs her.
In this complex situation, the therapist is challenged to work together with the
client to find a path that enables her to consider her own individual goals with-
out ignoring or devaluing her collectivistic cultural values. The therapist’s job is not
to take away her pain or struggle, or to choose for the client, but to be present in
such a way that the client will truly be empowered to make significant decisions.
The feminist counselor must remain aware that the price may be very high if this
woman chooses to go against what is culturally expected of her, and that the cli-
ent is the one to ultimately decide which path to follow. As can be seen from this
example, to minimize this potential shortcoming of imposing cultural values on a
client, it is essential that therapists understand how their own cultural perspectives
are likely to influence their interventions with culturally diverse clients. A safeguard
against value imposition is for feminist therapists to clearly present their values to
clients early in the course of the counseling relationship so that clients can make an
informed choice about continuing this relationship (Remer, 2013).
Stan’s fear of women and his gender-role socializa-tion experiences make him an excellent candidate
to benefit from feminist therapy. A therapeutic rela-
tionship that is egalitarian will be a new kind of experi-
ence for Stan.
Stan has indicated that he is willing and even
eager to change. Despite his low self-esteem and
negative self-evaluations, he is able to identify some
positive attributes. These include his determination,
his ability to articulate his feelings, and his gift for
working with children. Stan knows what he wants out
of therapy and has clear goals: to stop drinking, to feel
better about himself, to relate to women on an equal
basis, and to learn to love and trust himself and others.
Operating from a feminist orientation, I will build on
these strengths.
Feminist Therapy Applied to the Case of Stan
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356 C H A P T E R T W E LV E
In the first session I focus on establishing an
egalitarian working relationship to help Stan begin
to regain his personal power. It is important that the
therapeutic relationship does not replicate other rela-
tionships Stan has had with significant figures in his
life. I consciously work to demystify the therapeutic
process and equalize the relationship, conveying to
Stan that he is in charge of the direction of his therapy.
I spend time explaining my view of the therapy process
and how it works.
A gender-role analysis is conducted to help Stan
become aware of the influence of gender-role expecta-
tions in the development of his problems. First, I ask
him to identify gender-role messages he received while
growing up from his parents, teachers, the media, faith
community, and peers. In his autobiography Stan has
written about some of the messages his parents gave
him, and this provides a natural starting point for his
analysis. He remembers his father calling him “dumb”
and his mother saying, “Why can’t you grow up and
be a man?” Stan wrote about his mother “continu-
ally harping at” his father and telling Stan how she
wished she hadn’t had him. He describes his father as
weak, passive, and mousy in relating to his mother and
remembers that his father compared him unfavorably
with his siblings. Stan internalized these messages,
often crying himself to sleep and feeling very hopeless.
I ask Stan to identify the damaging self-statements
he makes now that are based on these early experi-
ences. As we review his writings, Stan sees how societal
messages he received about what a man “should” be
were reinforced by parental messages and have shaped
his view of himself today. For example, he wrote that
he feels sexually inadequate. It appears that he has
introjected the societal notion that men should always
initiate sex, be ready for sex, and be able to achieve and
sustain an erection. Stan also sees that he has already
identified and written about how he wants to change
those messages, as exemplified in his statements that
he wants to “feel equal with others” and not “feel apol-
ogetic” for his existence and develop a loving relation-
ship with a woman. Stan begins to feel capable and
empowered as I acknowledge the important work he
has already done, even before he entered therapy.
I follow this gender-role analysis with a gender-
role intervention to place Stan’s concerns in the con-
text of societal role expectations.
Therapist: Indeed, it is a burden to try to live up to so-
ciety’s notion of what it means to be a man, always
having to be strong and tough. Sometimes real
strength comes through our vulnerability. Those
aspects of yourself that you would like to value—
your ability to experience your feelings, being good
with children—are qualities society tends to label as
“‘feminine.”
Stan: [replies wistfully] Yeah, it would be a better world
if women could be strong without being seen as
domineering and if men could be sensitive and
nurturing without being seen as weak.
Therapist: Are you sure that’s not possible? Have you
ever met a woman or a man who was like that?
Stan ponders for a minute and then with some ani-
mation describes the college professor who taught
his Psychology of Adjustment class. Stan saw her as
very accomplished and strong, but also as someone
who empowered him by encouraging him to find his
own voice through writing his autobiography. He also
remembers a male counselor at the youth rehabilita-
tion facility where he spent part of his adolescence as
a man who was strong as well as sensitive and nurtur-
ing. I ask Stan if there are other people in his life now
who might support his efforts to be more accepting
and affirming of his androgyny.
As the first session draws to a close, I invite Stan
to talk about what he learned from our time together.
Stan says two things stand out for him. First, he is
beginning to believe he doesn’t need to keep blaming
himself. He knows that many of the messages he has
received from his parents and from society about what
it means to be a man have been undesirable and one-
dimensional. He acknowledges that he has been lim-
ited and constrained by his gender-role socialization.
Second, he feels hopeful because there are alternatives
to those parental and societal definitions—people he
admires have been able to successfully combine “mas-
culine” and “feminine” traits. If they can do it, so can
he. I ask Stan whether he chooses to return for another
session. When he answers in the affirmative, I give him
W. S. Pollack’s (1998) book Real Boys to read. I explain
that this book descriptively captures the gender-role
socialization that many boys experience.
Stan comes to the following session eager to talk
about his homework assignment. He tells me that he
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F E m i n i s T T H E R A P y 357
gained some real insights into his own attitudes and
beliefs by reading Real Boys. What Stan learned from
reading this book leads to a further exploration of his
relationship with his mother. He finds it helpful to
understand his parents’ behavior in the context of soci-
etal expectations and stereotypes rather than continu-
ing to blame them. I help Stan to see how our culture
tends to hold extreme positions about mothers—that
they are either perfect or wicked—and that neither of
these extremes is true. We talk briefly about what he
has learned about mothers as saints or sinners. As Stan
learns to reframe his relationship with his mother, he
develops a more realistic picture of her. He comes to
realize, too, that his father has been oppressed by his
own socialization experiences and by an idealistic view
of masculinity that he may have felt unable to achieve.
Stan continues to work at learning to value the
nurturing and sensitive aspects of himself. He is learn-
ing to value the “feminine” as well as the “masculine”
aspects of his personality. He continues to monitor
and make changes in his self-talk about what it means
to be a man. He is gaining awareness of these messages
that come from current sources such as the media and
friends, and each day he adds to his journal, noting
how these messages are transmitted and the ways that
he is challenging them.
Throughout our therapeutic relationship, we
discuss with immediacy how we are communicating
and relating to each other during the sessions. I am
self-disclosing and treat Stan as an equal, continually
acknowledging that he is the “expert” on his life.
Questions for Reflection
�� What unique values do you see in working with
Stan from a feminist perspective as opposed to
working from the other therapeutic approaches
you’ve studied thus far?
�� If you were to continue working with Stan, what
self-statements regarding his view of himself as a
man might you focus on, and what alternatives
might you offer?
�� In what ways could you integrate cognitive behav-
ior therapy with feminist therapy in Stan’s case?
What possibilities do you see for integrating
Gestalt therapy methods with feminist therapy?
What other therapies might you combine with a
feminist approach?
Visit CengageBrain.com or watch the video pro-
gram for Theory and Practice of Counseling and Psy-
chotherapy: The Case of Stan and Lecturettes, session
10 (feminist therapy), for a demonstration of my
approach to counseling stan from this perspec-
tive. This session deals with stan’s exploration
of his gender-role identity and messages he has
incorporated about being a man.
Powerlessness is the theme I hear from Gwen at the beginning of this session. She talks about her sad-
ness in seeing her granddaughter going through the
same things she experienced as a young girl. Gwen
feels invisible and unappreciated. I want to help Gwen
become aware of how gender-role socialization has in-
fluenced her and help her reclaim her personal power.
Gwen: I can’t tell you how many times in one day I tell
myself that I’m not worth anything.
Therapist: Give me an example of something that
happens to you and the message you hear inside
yourself.
Gwen: Well, in a meeting at work with the partners, I
may make a suggestion about something we might
do, but I’m ignored. Then Joe, this White guy,
makes the same suggestion with just a little twist
and the partners are all over it.
Therapist: So your voice is ignored, but the White
man gets heard. What do you tell yourself?
Gwen: I get really angry! If I say something, I am
accused of “always making it about race.” Then
I say to myself, “they are right because most of
the time it is about race.” I usually think, “here
we go again!”
Feminist Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a feminist therapy perspective and applying this model to Gwen.
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358 C H A P T E R T W E LV E
Therapist: Even though you push back against their
message, a part of you believes them—that you
are making too big a deal out of your voice being
ignored.
Gwen: No, I don’t believe that. Some things are about
being a woman of color and not being heard, and
that’s just how it is. Society ignores it, but it is real.
When someone does not know what it’s like to be
invisible and unheard, they are privileged! This is
an old, tired story for me.
Therapist: What did you learn growing up about the
value of your voice and your value as a girl and a
young woman?
Gwen: I learned that boys were valued more than girls.
I received the message that being a girl meant you
were not strong enough, not smart enough, and
that you were required to be in the kitchen cleaning
up after a meal.
I asked Gwen to write a gender-role analysis before
our next session. In it she provides more information
about the gender-role expectations in her home and in
her community as she was growing up. Gwen also writes
about telling an adult that her older cousin had touched
her inappropriately. She was told to be quiet about the
situation, and her sexual abuse was never spoken of
again. Gwen learned early that her voice did not matter.
In this session, I work toward validating her experiences
and the value of her voice. I acknowledge her pain and let
her know that society has perpetuated this unequal and
devaluing view of women and girls globally.
Therapist: Gwen, I read your gender-role analysis
thoroughly, and I really appreciate you trusting me
with the information you shared.
Gwen: It was hard.
Therapist: I’m sure it was. I was especially struck with
how early in your life you learned a lesson that too
many girls learn—that your voice didn’t count and
that your body was not yours. I am so sorry that
you had the experience of sexual abuse as a child
[It is important to name the reality of her experience and
not side-step it].
Gwen: I don’t think I realized until this moment what a
strong message was sent to me that day—the day I tried
to share with my mother what had happened to me.
Therapist: What message did you receive?
Gwen: My mother said, “Are you sure that happened?
I think you are making it up to get him in trouble!”
Therapist: In a culture where males are valued more
than females and where males have much more
power than females, the response you got from
your mother is often given directly or indirectly to
girls and women when they tell their truth about
being abused.
Gwen: I thought my mother would believe me and
would support me.
Therapist: You were and still are disappointed because
your mother, a person you trusted, silenced you.
And you’re confused about why she, as a woman,
would do this.
Gwen: Yes, I am.
Therapist: Keep in mind that your mother was raised
in the same culture in which the men are raised.
Women hear the same messages discounting
females that the men hear.
Gwen: You know, at work I get more angry at the
women than at the men. When I’m being discount-
ed and being told that I’m too angry and using the
“race card,” I rage more at the women than I do at
the men.
Therapist: What do you think that is about?
Gwen: Perhaps it is that I’m more disappointed in the
women for not standing with me. Or perhaps, like
my mother, I value the men more. It really hurts me
to believe that might be true.
By placing Gwen’s issue in a larger societal context, she
begins to understand that her experiences resonate with
the experiences of other women. It helps her to under-
stand that she, too, might be working from a model of
males being valued more than females. If she can get a
clear understanding of this, she can move more easily
to a place of truly believing in her own value.
Gwen is a professional woman with an MBA from
a prestigious university. She has had to continuously
negotiate minefields of racism, sexism, and multiple
forms of inequality. Institutional racism perpetuates
the oppression she has experienced and continues to
experience, but she sees that using her voice might
begin the process of healing her personal wounds
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F E m i n i s T T H E R A P y 359
from this societal injustice. I discuss with Gwen the
potential risks of using her voice (becoming more out-
spoken) in her present professional environment.
Gwen: I’m really tired of feeling angry all the time, but
I can tell you I’m also really tired of being treated as
“less than.”
Therapist: Tell me more about your experiences of
being treated as less than.
Gwen: If I raise my voice or express frustration at
work—even if I’m not angry—I am told that I’m too
emotional and too angry. I really feel that I’ve been
labeled “the angry black woman,” and no matter
how appropriate I am with my frustration or with
my voice, it is always seen as “there goes that angry
black woman again.”
Therapist: So, people at work have written this story
about you—angry black woman—and many things
that you do are filtered through the lens of that
story.
Gwen: Yes, that’s right.
Therapist: Think about the times when you are ap-
propriately speaking your mind and sharing your
frustration. Tell me what words you use to describe
yourself.
Gwen: [pause] Sometimes I am angry, and I have a
right to be, but I would say that I am being passion-
ate and assertive.
Therapist: I really like that! How might it be for you
to make sure that you restate in your own head
that message: “Gwen, you are being passionate and
assertive.” This is a way to define yourself.
Gwen: It is definitely something I would like to do.
Therapist: You have walked a path cluttered with
micro-aggressions for over 50 years, sometimes
experiencing these toxic messages multiple times
a day. As a woman of color, you are bombarded
with the messages from a culture that devalues
people of color and women. We can draw on the
strength of those who came before us. We are
standing on the shoulders of those who fought
for our rights as people of color and as women.
We know there is injustice in the fabric of our
society. What will you do to make changes that
are important to you?
Gwen: [Listening intently and reflecting on ways she has been
slighted] It feels good to talk about all this.
Therapist: You are an intelligent, passionate, creative,
and strong woman. I’m wondering how you might
use these parts of you to design your life to be more
the way you want it to be.
Gwen: I’m not sure. I do know that I want to be more
proactive in my community and more patient with
my mother. I’m learning that I still hold resent-
ments from my childhood, and I want to let
that go.
Therapist: That sounds like a good place to start.
Gwen: I also want to make sure that I handle my voice
and my frustration in the workplace appropriately.
I want my voice to be heard. Perhaps I can assert-
ively ask not to be interrupted when folks start to
interrupt me. When someone else is getting credit
for my idea, I will remind them that I had shared
it earlier. I will ask why it wasn’t heard when I pre-
sented it. I could do this calmly, but consistently.
Therapist: I think that is an excellent idea.
Gwen has been sitting on the curb of her life
watching the traffic go by for far too long. She does
not realize her own strength to create change. I share
with Gwen some of my challenges with racism. My
self-disclosure is intended to join with her in affirm-
ing that her experience of oppression is, in fact, valid.
As Gwen hears that she is not alone and that she can
begin to stand up and use her authentic voice, it is my
hope that Gwen will realize she can join with others
to make some change in society through conscious
action.
I collaborate with Gwen in identifying her
resources and deciding how she can make fuller use
of them in daily life. I become an ally and supporter
as she begins to create a plan of action for social and
personal transformation.
Therapist: You have shared some of the ways that you
want to be more visible in your work environment
and more assertive in your daily living. You have
also shared some ways that you plan on engaging
with your mother differently. I’m wondering if
there are any social groups you could become part
of that would help you feel more connected and
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360 C H A P T E R T W E LV E
involved in the community? Do you know some
other women who are also strong and with whom
you could find and offer support?
Gwen: There is a women’s group in my church that is
made up of professional women. I’ve avoided being
a part of it because I’m so busy and because I was
afraid that I wouldn’t fit in. There is one woman
in the group I trust, and I think I will talk with her
about ways I’m trying to restructure my life and see
if she thinks the group would be a good fit for me.
Therapist: So, she would serve for a while like your
mirror. She could reflect how she perceives you as
you interact with these women.
Gwen: I wasn’t thinking of it exactly in that way. It
will just feel good to have someone in the group
who I know and feel comfortable with.
As we continue our discussions in future sessions,
my goal is to help Gwen reclaim her power, increase her
self-esteem, and ultimately reach her full potential as
a valuable and significant member of her community.
Questions for Reflection
�� What reactions do you have to the therapist’s
interventions with Gwen?
�� What differences do you see when working with
Gwen from a feminist perspective rather than
from other theoretical frameworks?
�� What are your reactions to the therapist’s
self-disclosure?
�� What are potential dangers for Gwen if she
increasingly speaks her mind in professional
settings?
Summary and Evaluation
Summary
Feminist therapy largely grew out of the recognition by women that the
traditional models of therapy suffer from basic limitations due to the inherent bias
of earlier White male theoreticians. Feminist therapy emphasizes these concepts:
�� Viewing problems in a sociopolitical and cultural context rather than
on an individual level
�� Recognizing that clients are experts on their own lives
�� Striving to create a therapeutic relationship that is egalitarian through
the process of self-disclosure and informed consent
�� Demystifying the therapeutic process by including the client as much
as possible in all phases of assessment and treatment, which increases
client empowerment
�� Viewing women’s and other marginalized and oppressed group’s experi-
ences from a unique perspective
�� Understanding that gender never exists in isolation from other aspects
of identity
�� Understanding and appreciating the lives and perspectives of diverse
women and other marginalized and oppressed groups
�� Challenging traditional ways of assessing the psychological health of
women and other marginalized and oppressed groups
�� Emphasizing the role of the therapist as advocate as well as facilitator
�� Encouraging clients to get involved in social action to address oppres-
sive aspects of the environment
LO12
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F E m i n i s T T H E R A P y 361
The feminist approach is aimed at both personal and social change. The theo-
retical orientation is continually evolving and maturing. The major goal is to replace
the current patriarchal system with feminist consciousness and thus create a soci-
ety that values equality in relationships, values diversity, stresses interdependence
rather than dependence, and encourages both women and men to define themselves
rather than being defined by societal stereotypes.
Feminist practice tends to be diverse because it has been developed and expanded
by multiple voices. As the feminist approach has matured, it has become more self-
critical and varied. Feminist therapists and other therapists who infuse their work
with multicultural and social justice perspectives share a number of basic assump-
tions and roles: they engage in appropriate self-disclosure; they make their values
and beliefs explicit so that the therapy process is clearly understood; they establish
egalitarian roles with clients; they work toward client empowerment; they emphasize
the commonalities among women and other marginalized and oppressed groups
while honoring their diverse life experiences; and they all have an agenda to bring
about social change.
Feminist practitioners are committed to actively breaking down the hierarchy
of power in the therapeutic relationship through the use of various interventions.
Some of these strategies are unique to feminist therapy, such as gender-role analy-
sis and intervention, power analysis, assuming a stance of advocate in challenging
conventional attitudes toward appropriate roles for women, and encouraging cli-
ents to take social action. Other therapeutic strategies are borrowed from various
therapy models, including bibliotherapy, assertiveness training, cognitive restruc-
turing, reframing and relabeling, counselor self-disclosure, role playing, identifying
and challenging untested beliefs, and journal writing. Feminist therapy principles
and techniques can be applied to a range of therapeutic modalities such as individ-
ual therapy, couples counseling, family therapy, group counseling, and community
intervention. Regardless of the specific techniques used, the overriding goals are cli-
ent empowerment and social transformation.
Contributions of Feminist Therapy and Multicultural and
Social Justice Perspectives
One of the major contributions feminist theorists and practitioners have made to
the field of counseling and psychotherapy is paving the way for gender-sensitive prac-
tice and an awareness of the impact of the cultural context and multiple oppres-
sions. By focusing attention on our attitudes and biases pertaining to gender and
culture, feminist therapists have expanded the awareness of therapists of all theoreti-
cal orientations regarding how social justice issues may touch clients. A significant
contribution of feminist therapy is the emphasis on social change, which can lead
to a transformation in society. Feminist therapists have brought about significant
theoretical and professional advances in counseling practice. Some of these contri-
butions include power sharing with clients, cultural critiques of both assessment
and treatment approaches, and the validation of women and their normative experi-
ences. Feminist therapists have also made important contributions by questioning
the androcentricity of traditional counseling theories and models of human develop-
ment. Most theories place the cause of problems within individuals rather than with
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362 C H A P T E R T W E LV E
external circumstances and the environment. This has led to holding individuals
fully responsible for their problems and not giving recognition to social and political
realities that create problems. A key contribution feminist theorists and practitioners
continue to make is reminding all of us that the proper focus of therapy includes
addressing oppressive factors in society rather than expecting individuals to merely
adapt to expected role behaviors. This emphasis on social justice issues has expanded
the role of therapists to be advocates for clients. For a discussion of adaptations to
traditional approaches to counseling women, see Enns (2003).
Another major contribution of the feminist movement is in the area of ethics in
psychology and counseling practice (Brabeck & Brabeck, 2013). The unified feminist
voice called attention to the extent and implications of child abuse, incest, rape,
sexual harassment, and domestic violence. Feminists pointed out the consequences
of failing to recognize and take action when children and women were victims of
physical, sexual, and psychological abuse.
Feminist therapists demanded action in cases of sexual misconduct at a time
when male therapists misused the trust placed in them by their female clients. Not
too long ago the codes of ethics of all the major professional organizations were
silent on the matter of therapist and client sexual liaisons. Now, virtually all of the
professional codes of ethics prohibit sexual intimacies with current clients and with
former clients for a specified time period. Furthermore, the professions agree that a
sexual relationship cannot later be converted into a therapeutic relationship. Largely
due to the efforts and input of women on ethics committees, the existing codes are
explicit with respect to sexual harassment and sexual relationships with clients, stu-
dents, and supervisees (Herlihy & Corey, 2015b).
Feminist theory has been applied to supervision, teaching, consultation, ethics,
research, and theory building as well as to the practice of psychotherapy. Building
community, providing authentic mutual empathic relationships, creating a sense
of social awareness, and addressing social injustices are all significant strengths of
this approach.
The principles and techniques of feminist therapy can be incorporated in many
other contemporary therapy models and vice versa. Both feminist and Adlerian ther-
apists view the therapeutic relationship as egalitarian. Both feminist and person-
centered therapists agree on the importance of therapist authenticity, modeling,
and self-disclosure; empowerment is the basic goal of both orientations. When it
comes to making choices about one’s destiny, existential and feminist therapists are
speaking the same language—both emphasize choosing for oneself instead of living
a life determined by societal dictates.
Although feminist therapists have been critical of psychoanalysis as a sexist ori-
entation, a number of feminist therapists believe psychoanalysis can be an appropri-
ate approach to helping women. Object-relations theory may help clients examine
internalized object representations that are based on their relationships with their
parents. Indeed, relational-cultural therapy has roots in object-relations theory. Psy-
chodynamic approaches might include an examination of unconscious learning
about women’s roles through the mother–daughter relationship to provide insights
into why gender roles are so deeply ingrained and difficult to change.
Cognitive behavioral therapies and feminist therapy are compatible in that they
view the therapeutic relationship as a collaborative partnership, with the client being
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F E m i n i s T T H E R A P y 363
in charge of setting goals and selecting strategies for change. These approaches are
committed to demystifying therapy, and both aim to help clients take charge of their
own lives. Both the cognitive behavior therapist and the feminist therapist assume
a range of information-giving and teaching functions so clients can become active
partners in the therapy process. A feminist therapist could employ action-oriented
strategies, such as assertiveness training and behavioral rehearsal, and suggest home-
work assignments for clients to practice in their everyday lives. A useful source for
further discussion of feminist cognitive behavior therapy is Worell and Remer (2003).
Limitations and Criticisms of Feminist Counseling
Feminist therapists need to identify any sources of bias and work toward restructur-
ing or eliminating biased aspects in any theories or techniques they employ. This is
indeed a demanding endeavor, and it may involve the counselor’s own therapeutic
work and work with a consultant. It is possible for feminist therapists to unduly
influence clients, especially those who lack a strong sense of their own values. Femi-
nist therapists must remain aware of their own values pertaining to individual and
social change and explicitly share these values with clients in an appropriate, timely,
and respectful manner to reduce the risk of value imposition.
Feminist therapists call attention to clients’ unexamined choices, and they must
honor clients’ choices as long as those choices are indeed informed. Once clients
understand the impact of gender and cultural factors on their choices, the therapist
must guard against providing specific directions for client growth. Feminist thera-
pists are committed to helping clients weigh the costs and benefits of their current
life choices but should not push clients too quickly toward changes they feel are
beyond their reach. Lenore Walker (1994) raised this issue with regard to working
with abused women. Although Walker focuses on the importance of asking ques-
tions that enable women to think through their situations in new ways and of help-
ing women develop “safety plans,” she emphasizes how critical it is to understand
those factors in a woman’s life that often pose difficulties for her in making changes.
Looking at contextual or environmental factors that contribute to a woman’s
problems and moving away from exploring the intrapsychic domain can be both a
strength and a limitation. Instead of being blamed for her depression, the client is
able to come to an understanding of external realities that are indeed oppressive and
are contributing to her state of depression. A client can make some internal changes
even in those circumstances where external realities may largely be contributing to
her problems. Therapists must balance an exploration of the outer and inner worlds
of the client if the client is to find a way to take action in her own life.
Factors that inhibit the growth of feminist therapy include training that is often
offered only sporadically in a nonsystematic way (Brown, 2010) and the lack of qual-
ity control. No credentialing organization confers official status as a qualified feminist
therapist, so formalized training and credentialing need to be addressed in the future.
In addition, evidence-based research on the efficacy of feminist therapy is lacking, as is
an understanding of feminist therapy as an integrative approach that can inform ther-
apeutic practice for counselors of varied theoretical orientations. Feminist and most
other social justice psychotherapies do integrate evidenced-based treatment approaches
(e.g., CBT and trauma-focused interventions) within a social justice value system.
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364 C H A P T E R T W E LV E
Self-Reflection and Discussion Questions
1. What key concepts or principles of feminist therapy could you incor-
porate in your counseling practice regardless of your theoretical
orientation?
2. Feminist therapists engage in self-disclosure only when it is judged
to be therapeutically helpful to the client. How could you assess the
degree to which your personal disclosures are appropriate, timely, and
helpful to your client?
3. Feminist therapy aims to include social change as well as individual
change. How competent will you be in facilitating work with your cli-
ents in the area of social action?
4. This approach to therapy places value on exploring issues of power,
privilege, oppression, and discrimination. Do you see yourself as being
primarily interested in exploring these facets with your clients?
5. A number of feminist therapy techniques are described in this chapter.
What one technique do you find particularly interesting? Why?
Where to Go From Here
The DVD for Integrative Counseling: The Case of Ruth and Lecturettes is especially useful as
a demonstration of interventions I make with Ruth that illustrate some principles
and procedures of feminist therapy. For example, in Session 1 (“Beginning of Coun-
seling”) I ask Ruth about her expectations and initiate the informed consent pro-
cess. I attempt to engage Ruth as a collaborative partner in the therapeutic venture,
and I teach her how counseling works. Clearly, Ruth is the expert on her own life,
and my job is to assist her in attaining the goals we collaboratively identify as a focus
of therapy. In Session 4 (“Understanding and Dealing With Diversity”) Ruth brings
up gender differences, and she also mentions our differences in religion, education,
culture, and socialization. Ruth and I explore the degree to which she feels comfort-
able with me and trusts me.
Other Resources
DVDs offered by the American Psychological Association that are relevant to this
chapter include the following:
Brown, L. S. (2009). Feminist Therapy Over Time (APA Psychotherapy
Video Series)
Psychotherapy.net is a comprehensive resource for students and professionals
that offers videos and interviews on feminist therapy. New video and editorial con-
tent is made available monthly. DVDs relevant to this chapter are available at www
.psychotherapy.net and include the following:
Walker, L.(1994). The Abused Woman: A Survivor Therapy Approach
Walker, L. (1997). Feminist Therapy (Psychotherapy With the Experts Series)
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F E m i n i s T T H E R A P y 365
The Jean Baker Miller Training Institute offers workshops, courses, profes-
sional training, publications, and ongoing projects that explore applications of the
relational-cultural approach and integrate research, psychological theory, and social
action. This relational-cultural model is based on the assumption that growth-
fostering relationships and disconnections are constructed within specific cultural
contexts.
Jean Baker Miller Training Institute
www.wellesley.edu/JBMTI/
The American Psychological Association has two divisions devoted to spe-
cial interests in women’s issues: Division 17 (Counseling Psychology’s Section on
Women) and Division 35 (Psychology of Women).
American Psychological Association
www.apa.org
Division 17: www.div17.org
Division 35: www.apa.org/divisons/div35
The Association for Women in Psychology (AWP) sponsors an annual confer-
ence dealing with feminist contributions to the understanding of life experiences
of women. AWP is a scientific and educational feminist organization devoted to
reevaluating and reformulating the role that psychology and mental health research
generally play in women’s lives.
Association for Women in Psychology
www.awpsych.org
The Psychology of Women Resource List, or POWR online, is cosponsored by
APA Division 35, Society for the Psychology of Women, and the Association for
Women in Psychology. This public electronic network facilitates discussion of cur-
rent topics, research, teaching strategies, and practice issues among people inter-
ested in the discipline of psychology of women. Most people with computer access
to Bitnet or the Internet can subscribe to POWR-L at no cost. To subscribe, send the
command below via e-mail to:
LISTSERV@URIACC (Binet) or LISTSERV@URIACC.URI.EDU
Subscribe POWR-L Your name (Use first and last name)
The University of Kentucky offers a minor specialty area in counseling women
and feminist therapy within the Counseling Psychology graduate programs. For
information, contact Dr. Pam Remer:
University of Kentucky
Department of Educational and Counseling Psychology
www.uky.edu/Education/edphead.html
Texas Women’s University offers a training program with emphasis in women’s
issues, gender issues, and family psychology. For information, contact:
Texas Women’s University
www.twu.edu/as/psyphil/Counseling_Home.htm
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366 C H A P T E R T W E LV E
Recommended Supplementary Readings
Feminist Perspectives in Therapy: Empowering Diverse
Women (Worell & Remer, 2003) is an outstanding text
that clearly outlines the foundations of empower-
ment in feminist therapy. The book covers a range of
topics such as integrating feminist and multicultural
perspectives on therapy, changing roles for women,
feminist views of counseling practice, feminist trans-
formation of counseling theories, and a feminist
approach to assessment and diagnosis. There also
are excellent chapters dealing with depression, sur-
viving sexual assault, confronting abuse, choosing a
career path, and lesbian and ethnic minority women.
Oxford Handbook of Feminist Multicultural Counseling
Psychology (Enns & Williams, 2013) is a 26-chapter
handbook that integrates feminist and multicul-
tural scholarship and applies the perspective to a
variety of women’s diverse identities related to race/
ethnicity, social class, disability, religion, culture,
and so forth. Multiple chapters focus on the prac-
tice of feminist multicultural therapy, pedagogy,
mentoring, and social advocacy.
Psychological Practice With Women: Guidelines, Diver-
sity, Empowerment (Enns, Rice, & Nutt, 2015)
discusses the assessment of women’s social identities
and diversity and features chapters that focus on psy-
chotherapy with African American women; Latinas;
Asian American and Pacific Islander women; Native
women; lesbian, bisexual, and transgender women;
women with disabilities; and women in transna-
tional practice. Each chapter includes the applica-
tion of the APA (2007) Guidelines through one or
more case studies.
Feminist Therapy (Brown, 2010) provides an interest-
ing perspective on the history of feminist therapy
and speculates about future developments of the
approach. Brown clearly explains key concepts of
feminist theory and the therapeutic process.
Introduction to Feminist Therapy: Strategies for Social
and Individual Change (Evans, Kincade, & Seem,
2011) emphasizes the practical applications of
feminist theory to clinical practice. They provide
useful information on social change and empow-
erment, the importance of establishing an egali-
tarian relationship, and intervention strategies
when working with people from diverse cultural
backgrounds.
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367
13Postmodern Approaches
1. Identify how the postmodern
approaches differ from the
modernist approaches.
2. Describe the historical roots
of social constructionism.
3. Understand the collaborative
language systems approach.
4. Examine the distinguishing
features and key concepts of
solution-focused brief therapy.
5. Identify the role of the therapeutic
relationship in the solution-
focused approach.
6. Describe the techniques often
used by solution-focused brief
therapists.
7. Understand the application of
solution-focused therapy to group
counseling.
8. Identify the distinguishing features
and key concepts of narrative
therapy.
9. Understand the role of the
therapeutic relationship in
narrative therapy.
10. Describe the techniques often
used by narrative therapists.
11. Examine the application of
narrative therapy to group
counseling.
12. Identify the strengths and
shortcomings of the postmodern
approaches from a multicultural
perspective.
13. Describe the contributions and
limitations of the postmodern
approaches.
L e a r n i n g O b j e c t i v e s
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368 C H A P T E R T H I R T E E N
Some Contemporary Founders of Postmodern Therapies
The postmodern approaches do not have a single founder. Rather, it has been a col-
lective effort by many. I have highlighted two cofounders of solution-focused brief
therapy and two cofounders of narrative therapy who have had a major impact on
the development of these therapeutic approaches. These cofounders are introduced
at the beginning of the sections on these therapies.
Introduction to Social Constructionism
Each of the models of counseling and psychotherapy we have studied so far
has its own version of “reality.” The simultaneous existence of multiple and often
conflicting “truths” has led to increasing skepticism that a singular, universal the-
ory will one day explain human behavior and the systems in which we live. We have
entered a postmodern world, and truth and reality are often now understood as rep-
resenting points of view bounded by history and context rather than being objec-
tive, immutable facts.
Modernists believe in the ability to describe objective reality accurately and
assume that it can be observed and systematically known through the scientific
method. They further believe reality exists independent of any attempt to observe it.
Modernists believe people seek therapy for a problem when they have deviated too
far from some objective norm. For example, clients may think they are abnormally
depressed when they experience sadness for longer than they think is normal. They
might then seek help to return to “normal” behavior.
Postmodernists, in contrast, do not believe realities exist independent of obser-
vational processes and of the language systems within which they are described.
social constructionism is a psychological expression of this postmodern world-
view; it values the client’s reality without disputing whether it is accurate or rational
(Gergen, 1991, 1999; Weishaar, 1993). To social constructionists, any understanding
of reality is based on the use of language and is largely a function of the situations
in which people live. Our knowledge about realities is socially constructed. A person
is depressed when he or she adopts a definition of self as depressed. Without the
cultural conditions that accept the concept of depression, talking about a person
as depressed would mean nothing. Once a definition of self is adopted, it is hard to
recognize behaviors counter to that definition; for example, it is hard for someone
who is suffering from depression to acknowledge the value of a periodic good mood
in his or her life.
In postmodern thinking, forms of language and the use of language in stories
create meaning. There may be as many meanings as there are people to tell the sto-
ries, and each of these stories expresses a truth for the person telling it. Even science
is not free from the influence of such processes of social construction. Every person
involved in a situation has a perspective on the “reality” of that situation, but the
range of truths is limited due to the effects of specific historical events and the lan-
guage uses that dominate particular social contexts. In practice, therefore, the range
of possible meanings is not infinite. When Kenneth Gergen (1985, 1991, 1999) and
others began to emphasize the ways in which people make meaning in social rela-
tionships, the field of social constructionism was born.
LO1
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P o s T m o d E R N A P P R o A C H E s 369
In social constructionism the therapist disavows the role of expert, preferring a
more collaborative or consultative stance. Clients are viewed as experts about their
own lives. De Jong and Berg (2013) put this notion about the therapist’s task well:
We do not view ourselves as expert at scientifically assessing client problems and
then intervening. Instead, we strive to be expert at exploring clients’ frames of
reference and identifying those perceptions that clients can use to create more
satisfying lives. (p. 19)
The collaborative partnership in the therapeutic process is considered more impor-
tant than assessment or technique. Understanding narratives and deconstructing
language processes (discourses) are the focus for both understanding individuals
and helping them construct desired change.
Social constructionist theory is grounded on the premise that knowledge is con-
structed through social processes. What we consider to be “truth” is a product of
interactions between people in daily life. Thus there is not a single or “right” way
to live one’s life or to understand the world. Social constructionism explains how
values are transmitted through language by the social milieu and suggests that indi-
viduals are constantly changing with the ebb and flow of the influences of family,
culture, and society (Neukrug, 2016).
Visit CengageBrain.com or watch the dVd for the video program on Chapter 13, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Historical Glimpse of Social Constructionism
A mere hundred years ago, Freud, Adler, and Jung were part of a major para-
digm shift that transformed psychology as well as philosophy, science, medicine, and
even the arts. In the 21st century, postmodern constructions of alternative knowl-
edge sources seem to be one of the paradigm shifts most likely to affect the field
of psychotherapy. Postmodernist thought is influencing the development of many
psychotherapy theories and contemporary psychotherapeutic practice. The creation
of the self, which so dominated the modernist search for human essence and truth,
is being replaced with the concept of socially storied lives. Diversity, multiple frame-
works, and integration—collaboration of the knower with the known—are all part of
this new social movement, which provides a wider range of perspectives in counsel-
ing practice. For some social constructionists, the process of “knowing” includes a
distrust of the dominant cultural positions that permeate families and society today
(White & Epston, 1990), particularly when the dominant culture exerts a destructive
impact on the lives of those who live beyond the margins of what is generally consid-
ered normal. Change begins by deconstructing the power of cultural narratives and
then proceeds to the co-construction of a new life of meaning.
Among the best-known postmodern perspectives on therapy practice are the
collaborative language systems approach (Anderson & Goolishian, 1992), solution-
focused brief therapy (de Shazer, 1985, 1988, 1991, 1994), solution-oriented therapy
(Bertolino & O’Hanlon, 2002; O’Hanlon & Weiner-Davis, 2003), narrative therapy
(White & Epston, 1990), and feminist therapy (Brown, 2010). The next section exam-
ines the collaborative language systems approach, but the heart of this chapter
LO2
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370 C H A P T E R T H I R T E E N
addresses two of the most significant postmodern approaches: solution-focused
brief therapy and narrative therapy.
The Collaborative Language Systems Approach
When people seek therapy, they are often “stuck” in a dialogic system that has
a unique language, meaning, and process related to “the problem.” Therapy is another
conversational system that becomes therapeutic through its “problem-organizing,
problem-dissolving” nature (Anderson & Goolishian, 1992, p. 27). It is therapists’
willingness to enter the therapeutic conversation from a “not-knowing” position that
facilitates this caring relationship with the client. In the not-knowing position, therapists
still retain all of the knowledge and personal, experiential capacities they have gained
over years of living, but they allow themselves to enter the conversation with curiosity
and with an intense interest in discovery. The aim here is to enter a client’s world as
fully as possible. Clients become the experts who are informing and sharing with the
therapist the significant narratives of their lives. The not-knowing position is empathic
and is most often characterized by questions that “come from an honest, continuous
therapeutic posture of not understanding too quickly” (Anderson, 1993, p. 331).
Based on the referral or intake process, the therapist enters the session with some
sense of what the client may wish to address. The questions the therapist asks are
informed by the answers the client-expert has provided. The client’s answers provide
information that stimulates the interest of the therapist, still in a posture of inquiry,
and another question proceeds from each answer given. The process is similar to the
Socratic method without any preconceived idea about how or in which direction the
development of the stories should go. The intent of the conversation is not to con-
front or challenge the narrative of the client but to facilitate the telling and retelling
of the story until opportunities for new meaning and new stories develop: “Telling
one’s story is a representation of experience; it is constructing history in the present”
(Anderson & Goolishian, 1992, p. 37). By staying with the story, the therapist–client
conversation evolves into a dialogue of new meaning, constructing new narrative
possibilities. This not-knowing position of the therapist has been infused as a key
concept for both the solution-focused and the narrative therapeutic approaches.
LO3
INSOO KIM BERG (1935–2007) was a
Korean-born American psychothera-
pist and a pioneer of solution-focused
brief therapy (SFBT). In 1978 she
and her husband, Steve de Shazer,
cofounded the Brief Family Therapy
Center in Milwaukee, Wisconsin. As
a leader in the practice of SFBT, she
provided workshops in the United
States, Japan, South Korea, Australia,
Denmark, England, and Germany.
Berg published 10 groundbreaking
books that elucidated the application
of SFBT in a wide variety of clinical set-
tings; among them are Family Based Ser-
vices: A Solution-Focused Approach (1994),
Working With the Problem Drinker: A
Solution-Focused Approach (Berg & Miller,
1992), and Interviewing for Solutions (De
Jong & Berg, 2013). Berg’s colleagues
described her as inspiring, humble, and
passionate. She was committed to her
work and rarely took time off, but she
did enjoy a wide range of physical activi-
ties: stretching exercises, yoga, walking,
and gardening.
Insoo Kim Berg
Co
ur
te
sy
o
f B
rie
f F
am
ily
T
he
ra
py
C
en
te
r
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P o s T m o d E R N A P P R o A C H E s 371
Solution-Focused Brief Therapy
Introduction
solution-focused brief therapy (SFBT) is a future-focused, goal-oriented thera-
peutic approach to brief therapy developed initially by Steve de Shazer and Insoo
Kim Berg at the Brief Family Therapy Center in Milwaukee in the early 1980s. SFBT
emphasizes strengths and resiliencies of people by focusing on exceptions to their
problems and their conceptualized solutions. SFBT is an optimistic, antidetermin-
istic, future-oriented approach based on the assumption that clients have the ability
to change quickly and can create a problem-free language as they strive for a new
reality (Neukrug, 2016).
Key Concepts
Unique Focus of SFBT The solution-focused philosophy rests on the
assumption that people can become mired in unresolved past conflicts and blocked
when they focus on past or present problems rather than on future solutions.
Solution-focused brief therapy differs from traditional therapies by eschewing
the past in favor of both the present and the future (Franklin, Trepper, Gingerich,
& McCollum, 2012). Therapists focus on what is possible, and they have little or
no interest in gaining an understanding of how the problem emerged. Behavior
change is viewed as the most effective approach to assisting people in enhancing
their lives. De Shazer (1988, 1991) suggests that it is not necessary to know the
cause of a problem to solve it and that there is no necessary relationship between
the causes of problems and their solutions. Assessing problems is not necessary for
change to occur. If knowing and understanding problems are unimportant, so is
searching for “right” or absolute solutions. Any person might consider multiple
solutions, and what is right for one person may not be right for others.
It is within the scope of SFBT practice to allow for some discussion of present-
ing problems to validate clients’ experience and to let them describe their pain,
STEVE de SHAZER (1940–2005) was
one of the pioneers of solution-focused
brief therapy. For many years he was
the director of research at the Brief
Family Therapy Center in Milwaukee,
where solution-focused brief therapy
was developed. He wrote several books
on SFBT, including Keys to Solutions in
Brief Therapy (1985), Clues: Investigating
Solutions in Brief Therapy (1988), Putting
Difference to Work (1991), and Words Were
Originally Magic (1994).
De Shazer loved baseball, was a
gourmet cook, and made time for long daily walks.
Some of his leisure pursuits included
reading philosophy tracts in the origi-
nal German or French, listening to jazz,
and perusing esoteric cookbooks. He
was trained as a classical musician and
played several instruments at a profes-
sional level. During his youth he made
his living as a jazz saxophonist. He pre-
sented workshops, trained, and con-
sulted widely in North America, Europe,
Australia, and Asia. While on a teaching
tour in Europe in 2005, de Shazer went
to a hospital in Vienna for medical help;
he died several hours after being admitted.
Steve de Shazer
Co
ur
te
sy
o
f B
rie
f F
am
ily
T
he
ra
py
C
en
te
r
LO4
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372 C H A P T E R T H I R T E E N
struggles, and frustrations (Murphy, 2013, 2015). However, this brief exploration
differs from the lengthy discourse into the history and causes of problems common
to some other types of therapy. In solution-focused brief therapy, clients choose the
goals they wish to accomplish; little attention is given to diagnosis, history taking,
or exploring the emergence of the problem (O’Hanlon & Weiner-Davis, 2003).
Positive Orientation Solution-focused brief therapy is grounded on the optimistic
assumption that people are healthy and competent and have the ability to construct
solutions that can enhance their lives. An underlying assumption of SFBT is that
we already have the ability to resolve the challenges life brings us, but at times
we lose our sense of direction or our awareness of our competencies. Regardless
of what shape clients are in when they enter therapy, solution-focused therapists
believe clients are competent. The therapist’s role is to help clients recognize the
competencies they already possess and apply them toward solutions. The essence
of therapy involves building on clients’ hope and optimism by creating positive
expectations that change is possible. Solution-focused brief therapy has parallels
with positive psychology, which concentrates on what is right and what is working
for people rather than dwelling on deficits, weaknesses, and problems (Murphy,
2015). By emphasizing positive dimensions, clients quickly become involved in
resolving their problems, which makes this a very empowering approach.
Because clients often come to therapy in a “problem-oriented” state, even the
few solutions they have considered are wrapped in the power of the problem ori-
entation. Clients often have a story that is rooted in a deterministic view that what
has happened in their past will certainly shape their future. Solution-focused practi-
tioners counter this negative client presentation with optimistic conversations that
highlight a belief in achievable and usable goals. Therapists can be instrumental in
assisting clients in making a shift from a fixed problem state to a world with new
possibilities. One of the goals of SFBT is to shift clients’ perceptions by reframing
what White and Epston (1990) refer to as clients’ problem-saturated stories through the
counselor’s skillful use of language.
Looking for What Is Working The emphasis of SFBT is to focus on what is
working in clients’ lives, which stands in stark contrast to the traditional models
of therapy that tend to be problem-focused. Individuals bring stories to therapy,
some of which are used to justify the client’s belief that life can’t be changed or,
worse, that life is moving them further and further away from their goals. Solution-
focused brief therapists assist clients in paying attention to the exceptions to their
problem patterns, or their instances of success. They promote hope by helping
clients discover exceptions, or times when the problem is less intrusive in their life
(Metcalf, 2001). SFBT focuses on finding out what people are doing that is working
and then helping them apply this knowledge to eliminate problems in the shortest
amount of time possible. Identifying what is working and encouraging clients
to replicate these patterns is extremely important (Murphy, 2015). A key theme
of SFBT is, When you know what is working, do more of it. If something is not
working, try something different (Hoyt, 2015).
There are various ways to assist clients in thinking about what has worked
for them. De Shazer (1991) prefers to engage clients in conversations that lead to
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P o s T m o d E R N A P P R o A C H E s 373
progressive narratives whereby people create situations in which they can make
steady gains toward their goals. De Shazer might say, “Tell me about times when
you felt a little better and when things were going your way.” It is in these stories of
life worth living that the power of problems is deconstructed and new solutions are
manifest and made possible.
Basic Assumptions Guiding Practice Walter and Peller (1992, 2000) think of
solution-focused therapy as a model that explains how people change and how they
can reach their goals rather than a model of the causes of problems. Here are some
of their basic assumptions about solution-focused therapy:
�� Individuals who come to therapy do have the capability of behaving
effectively, even though this effectiveness may be temporarily blocked
by negative cognitions. Problem-focused thinking prevents people from
recognizing effective ways they have dealt with problems.
�� There are advantages to a positive focus on solutions and on the future.
If clients can reorient themselves in the direction of their strengths
using solution-talk, there is a good chance therapy can be brief.
�� There are exceptions to every problem, or times when the problem
was absent. By talking about these exceptions, clients can get clues to
effective solutions and can gain control over what had seemed to be an
insurmountable personal difficulty. Rapid changes are possible when
clients identify exceptions to their problems and begin to organize their
thinking around these exceptions instead of around the problem.
�� Clients often present only one side of themselves. Solution-focused thera-
pists invite clients to examine another side of the story they are presenting.
�� No problem is constant, and change is inevitable. What people need to do
is become aware of any positive changes that are happening. Small changes
pave the way for larger changes, and these changes are often all that is needed
to resolve the problems clients bring to counseling (Guterman, 2013).
�� Clients are doing their best to make change happen. Therapists should
adopt a cooperative stance with clients rather than devising strategies
to control resistive patterns. When therapists find ways to cooperate
with people, resistance does not occur.
�� Clients can be trusted in their intention to solve their problems. Thera-
pists assume that clients want to change, can change, and will change
under cooperative and empowering therapeutic conditions. There are
no “right” solutions to specific problems that can be applied to all peo-
ple. Each individual is unique and so, too, is each solution.
Characteristics of Brief Therapy The average length of therapy is three to eight
sessions, with the most common length being only one session (Hoyt, 2015). The
main goal of brief therapy is to help clients efficiently resolve problems and to move
forward as quickly as possible. Some of the defining characteristics of brief therapy
include the following (Hoyt, 2009, 2011, 2015):
�� Rapid working alliance between therapist and client
�� Clear specification of achievable treatment goals
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374 C H A P T E R T H I R T E E N
�� Clear division of responsibilities between client and therapist, with
active client participation and a high level of therapist activity
�� Emphasis on client’s strengths, competencies, and adaptive capacities
�� Expectation that change is possible and realistic and that improvement
can occur in the immediate future
�� Here-and-now orientation with a primary focus on current functioning
in thinking, feeling, and behaving
�� Specific, integrated, pragmatic, and eclectic techniques
�� Periodic assessment of progress toward goals and outcomes
�� Time sensitive, including making the most of each session and ending
therapy as soon as possible
The core task is for SFBT practitioners to learn how to rapidly and systemati-
cally identify problems, create a collaborative relationship with clients, and intervene
with a range of specific methods. Because most therapy is time-limited, therapists
should learn to practice brief therapy well (Hoyt, 2011).
The Therapeutic Process
The therapeutic process rests on the foundation that clients are the experts on their
own lives and often have a good sense of what has or has not worked in the past
and what might work in the future. Solution-focused counseling assumes a col-
laborative approach with clients in contrast to the educative stance that is typically
associated with most traditional models of therapy. If clients are involved in the
therapeutic process from beginning to end, the chances are increased that therapy
will be successful. In short, collaborative and cooperative relationships tend to be
more effective than hierarchical relationships in therapy.
De Shazer (1991) believes clients can generally build solutions to their prob-
lems without any assessment of the nature of their problems. Given this frame-
work, the structure of solution building differs greatly from traditional approaches
to problem solving as can be seen in this brief description of the steps involved
(De Jong & Berg, 2013):
1. Clients are given an opportunity to describe their problems. The thera-
pist listens respectfully and carefully as clients answer the therapist’s
question, “How can I be useful to you?”
2. The therapist works with clients in developing well-formed goals as
soon as possible. The question is posed, “What will be different in your
life when your problems are solved?”
3. The therapist asks clients about those times when their problems were
not present or when the problems were less severe. Clients are assisted
in exploring these exceptions, with special emphasis on what they did
to make these events happen.
4. At the end of each solution-building conversation, the therapist offers
clients summary feedback, provides encouragement, and suggests
what clients might observe or do before the next session to further
solve their problem.
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P o s T m o d E R N A P P R o A C H E s 375
5. The therapist and clients evaluate the progress being made in reaching
satisfactory solutions by using a rating scale. Clients are asked what
needs to be done before they see their problem as being solved and also
what their next step will be.
Therapeutic Goals SFBT reflects some basic notions about change, about interaction,
and about reaching goals. The solution-focused therapist believes people have
the ability to define meaningful personal goals and that they have the resources
required to solve their problems. Goals are unique to each client and are constructed
by the client to create a richer future (Prochaska & Norcross, 2014). A lack of
clarity regarding client preferences, goals, and desired outcomes can result in a rift
between therapist and client. During the early phase of therapy, it is important
that clients be given the opportunity to express what they want from therapy and
what concerns they are willing to explore. From the first contact with clients, the
therapist strives to create a climate that will facilitate change and encourage clients
to think in terms of a range of possibilities.
Solution-focused therapists concentrate on small, realistic, achievable changes
that can lead to additional positive outcomes. Because success tends to build upon
itself, modest goals are viewed as the beginning of change. The therapist looks for
ways to amplify the client’s movement in the desired direction as quickly as possible
(Hoyt, 2015). Solution-focused therapists use questions such as these that presup-
pose change, posit multiple answers, and remain goal-directed and future-oriented:
“What did you do, and what has changed since last time?” or “What did you notice
that went better?” (Bubenzer & West, 1993).
Murphy (2015) emphasizes the importance of assisting clients in creating well-
defined goals that are (1) stated positively in the client’s language; (2) are action-
oriented; (3) are structured in the here and now; (4) are attainable, concrete, specific,
and measurable; and (5) are controlled by the client. Counselors should not too
rigidly impose an agenda of getting precise goals before clients have a chance to
express their concerns. Clients must feel that their concerns are heard and under-
stood before they can formulate meaningful personal goals. In a therapist’s zeal to
be solution-focused, it is possible to get lost in the mechanics of therapy and not
attend sufficiently to the interpersonal aspects. Therapists need to be mindful of not
becoming overly technique driven at the expense of the therapeutic alliance.
Solution-oriented therapy offers several forms of goals: changing the viewing
of a situation or a frame of reference, changing the doing of the problematic situ-
ation, and tapping client strengths and resources (O’Hanlon & Weiner-Davis, 2003).
Therapists note the language they use, so they can increase their clients’ hope and
optimism and their openness to possibilities and change. Clients are encouraged to
engage in change- or solution-talk, rather than problem-talk, on the assumption
that what we talk about most will be what we produce. Talking about problems can
produce ongoing problems. Talk about change can produce change.
Therapist’s Function and Role Solution-focused practitioners believe that every
client is motivated in the sense that he or she wants something as a consequence of
meeting with a therapist (George, Iveson, & Ratner, 2015). Clients are much more
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376 C H A P T E R T H I R T E E N
likely to get involved in the therapeutic process if they believe they are determining
the direction and purpose of the conversation. Much of what the therapeutic process
is about involves clients’ thinking about their future and what they want to be
different in their lives. Consistent with the postmodern and social constructionist
perspective, solution-focused brief therapists adopt a not-knowing position to put clients
in the position of being the experts about their own lives. Therapists do not assume
that by virtue of their expert frame of reference they know the significance of the
client’s actions and experiences (Anderson & Goolishian, 1992). This model casts the
role and function of a therapist in quite a different light from traditionally oriented
therapists who view themselves as experts in assessment and treatment. The therapist-
as-expert is replaced by the client-as-expert, especially when it comes to what the client
wants in life and in therapy. It is important that therapists actually believe that their
clients are the true experts on their own lives. Although therapists have expertise in
the process of change, clients are the experts on what they want changed. Clients will
have their own ways of building their preferred futures, even if this is often not clear to
them when they begin therapy. The therapist’s task is to point clients in the direction
of change without dictating what to change (George et al., 2015; Guterman, 2013).
Therapists strive to create a climate of mutual respect, dialogue, and affirma-
tion in which clients experience the freedom to create, explore, and coauthor their
evolving stories. A key therapeutic task consists of helping clients imagine how they
would like life to be different and what it would take to make this transformation
happen. One of the functions of the therapist is to ask questions and, based on the
answers, generate further questions. Examples of some useful questions are “What
do you hope to gain from coming here?” “If you were to make the changes you desire,
how would that make a difference in your life?” and “What steps can you take now
that will lead to these changes?”
The Therapeutic Relationship The quality of the relationship between
therapist and client is a determining factor in the outcomes of SFBT, so relationship
building or engagement is a basic step in SFBT. The attitude of the therapist is
crucial to the effectiveness of the therapeutic process. It is essential to create a
sense of trust so clients will return for further sessions and will follow through on
homework suggestions. The therapeutic process works best when clients become
actively involved, when they experience a positive relationship with the therapist,
and when counseling addresses what clients see as being important (Murphy, 2015).
One way of creating an effective therapeutic partnership is for the therapist to show
clients how they can use the strengths and resources they already have to construct
solutions. Clients are encouraged to do something different and to be creative in
thinking about ways to deal with their present and future concerns.
De Shazer (1988) has described three kinds of relationships that may develop
between therapists and their clients:
1. Customer: the client and therapist jointly identify a problem and a solu-
tion to work toward. The client realizes that to attain his or her goals,
personal effort will be required.
2. Complainant: the client describes a problem but is not able or willing
to assume a role in constructing a solution, believing that a solution
LO5
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P o s T m o d E R N A P P R o A C H E s 377
is dependent on someone else’s actions. In this situation, the client
generally expects the therapist to change the other person to whom the
client attributes the problem.
3. Visitor: the client comes to therapy because someone else (a spouse, par-
ent, teacher, or probation officer) thinks the client has a problem. This
client may not agree that he or she has a problem and may be unable to
identify anything to explore in therapy.
De Jong and Berg (2013) recommend using caution so that therapists do not
box clients into static identities. These three roles are only starting points for con-
versation. Rather than categorizing clients, therapists can reflect on the kinds of
relationships that are developing between their clients and themselves. For example,
clients who tend to place the cause of their problems on another person or persons
in their lives (complainants) may be helped by skilled intervention to begin to see
their own role in their problems and the necessity for taking active steps in creating
solutions. How the therapist responds to different behaviors of clients has a lot to
do with bringing about a shift in the relationship. In short, both complainants and
visitors have the capacity for becoming customers.
Application: Therapeutic Techniques and Procedures
Some of the key techniques that solution-focused practitioners are likely
to employ include looking for differences in doing, exception questions, scaling
questions, and the miracle question. If these techniques are used in a routine way
without developing a collaborative working alliance, they will not lead to effective
results. Murphy (2015) reminds us that these solution-focused techniques should
be used flexibly and tailored to the unique circumstances of each client. Therapy
is best guided by the client’s goals, perceptions, resources, and feedback. Therapy
should not be determined by any absolutes or rigid standards outside the therapeu-
tic relationship (namely, evidence-based treatments).
Pretherapy Change Simply scheduling an appointment often sets positive change
in motion. During the initial therapy session, it is common for solution-focused
therapists to ask, “What have you done since you called for the appointment that
has made a difference in your problem?” (de Shazer, 1985, 1988). By asking about
such changes, the therapist can elicit, evoke, and amplify what clients have already
done by way of making positive change. These changes cannot be attributed to the
therapy process itself, so asking about them tends to encourage clients to rely less on
their therapist and more on their own resources to accomplish their treatment goals.
Exception Questions SFBT is based on the notion that there were times in
clients’ lives when the problems they identify were not problematic. These times are
called exceptions and represent news of difference (Bateson, 1972). Solution-focused
therapists ask exception questions to direct clients to times when the problem
did not exist, or when the problem was not as intense. exceptions are those past
experiences in a client’s life when it would be reasonable to have expected the
problem to occur, but somehow it did not (de Shazer, 1985; Murphy, 2015).
LO6
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378 C H A P T E R T H I R T E E N
By helping clients identify and examine these exceptions, the chances are increased
that they will work toward solutions (Guterman, 2013). Once identified by an
individual, these instances of success can be useful in making further changes. This
exploration reminds clients that problems are not all-powerful and have not existed
forever; it also provides a field of opportunity for evoking resources, engaging
strengths, and positing possible solutions. The therapist asks clients what has to
happen for these exceptions to occur more often.
The Miracle Question Therapy goals are developed by using what de Shazer
(1988) calls the miracle question, which is a main SFBT technique. The therapist
asks, “If a miracle happened and the problem you have was solved overnight, how
would you know it was solved, and what would be different?” Clients are then
encouraged to enact “what would be different” in spite of perceived problems. If a
client asserts that she wants to feel more confident and secure, the therapist might
say: “Let yourself imagine that you leave the office today and that you are on track
to acting more confidently and securely. What will you be doing differently?” This
process of considering hypothetical solutions reflects O’Hanlon and Weiner-Davis’s
(2003) belief that changing the doing and viewing of the perceived problem changes
the problem.
De Jong and Berg (2013) identify several reasons the miracle question is a useful
technique. Asking clients to consider that a miracle takes place opens up a range of
future possibilities. Clients are encouraged to allow themselves to dream as a way of
identifying the kinds of changes they most want to see. This question has a future
focus in that clients can begin to consider a different kind of life that is not domi-
nated by a particular problem. This intervention shifts the emphasis from both past
and current problems toward a more satisfying life in the future.
Scaling Questions Solution-focused therapists also use scaling questions when
change in human experiences are not easily observed, such as feelings, moods,
or communication, and to assist clients in noticing that they are not completely
defeated by their problem (de Shazer & Berg, 1988). For example, a woman reporting
feelings of panic or anxiety might be asked: “On a scale of zero to 10, with zero being
how you felt when you first came to therapy and 10 being how you feel the day after
your miracle occurs and your problem is gone, how would you rate your anxiety
right now?” Even if the client has only moved away from zero to 1, she has improved.
How did she do that? What does she need to do to move another number up the
scale? Scaling questions enable clients to pay closer attention to what they are doing
and how they can take steps that will lead to the changes they desire.
Formula First Session Task The formula first session task (FFST) is a form of
homework a therapist might give clients to complete between their first and second
sessions. The therapist might say: “Between now and the next time we meet, I would
like you to observe, so that you can describe to me next time, what happens in your
(family, life, marriage, relationship) that you want to continue to have happen” (de
Shazer, 1985, p. 137). At the second session, clients can be asked what they observed
and what they would like to have happen in the future. This kind of assignment
offers clients hope that change is inevitable. It is not a matter of if change will occur,
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P o s T m o d E R N A P P R o A C H E s 379
but when it will happen. According to de Shazer, this intervention tends to increase
clients’ optimism and hope about their present and future situation. The FFST
technique emphasizes future solutions rather than past problems (Murphy, 2015).
Therapist Feedback to Clients Solution-focused practitioners generally take a
break of 5 to 10 minutes toward the end of each session to compose a summary
message for clients. During this break therapists formulate feedback that will be
given to clients after the break. The summary might contain strengths the therapist
has noticed about the client during the session, signs of hope and identifying
exceptions to a problem, and a commentary on what the client is already doing that
is useful in moving in a desired direction (George et al., 2015).
De Jong and Berg (2013) describe three basic parts to the structure of the sum-
mary feedback: compliments, a bridge, and suggesting a task. Compliments are genu-
ine affirmations of what clients are already doing that is leading toward effective
solutions. It is important that complimenting is not done in a routine or mechani-
cal way, but in an encouraging manner that creates hope and conveys the expecta-
tion to clients that they can achieve their goals by drawing on their strengths and
successes. Second, a bridge links the initial compliments to the suggested tasks that
will be given. The bridge provides the rationale for the suggestions. The third aspect
of feedback consists of suggesting tasks to clients, which can be considered as home-
work. Observational tasks ask clients to simply pay attention to some aspect of their
lives. This self-monitoring process helps clients note the differences when things are
better, especially what was different about the way they thought, felt, or behaved.
Behavioral tasks require that clients actually do something the therapist believes
would be useful to them in constructing solutions. De Jong and Berg (2013) stress
that a therapist’s feedback to clients addresses what they need to do more of and do
differently in order to increase the chances of obtaining their goals.
Terminating From the very first solution-focused interview, the therapist is mindful
of working toward termination. Once clients are able to construct a satisfactory
solution, the therapeutic relationship can be terminated. The initial goal-formation
question that a therapist often asks is, “What needs to be different in your life as a
result of coming here for you to say that meeting with me was worthwhile?” Through
the use of scaling questions, therapists can assist clients in monitoring their progress
so clients can determine when they no longer need to come to therapy (De Jong & Berg,
2013). Establishing clear goals from the beginning of therapy lays the groundwork for
effective termination (Murphy, 2015). Prior to ending therapy, therapists assist clients
in identifying things they can do to continue the changes they have already made into
the future. Clients can also be helped to identify hurdles or perceived barriers that
could get in the way of maintaining the changes they have made.
Guterman (2013) maintains that the ultimate goal of solution-focused counsel-
ing is to end treatment. He adds, “If counselors are not proactive in making their
treatment brief by design, then in many cases counseling will be brief by default”
(p. 104). Because this model of therapy is brief, present-centered, and addresses spe-
cific complaints, it is very possible that clients will experience other developmental
concerns at a later time. Clients can be invited to ask for additional sessions when-
ever they feel a need to get their life back on track or to update their story.
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380 C H A P T E R T H I R T E E N
Dr. John Murphy puts many SFBT techniques into action as he illustrates
assessment and treatment from a solution-focused brief therapy approach in the
case of Ruth in Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11).
Application to Group Counseling The solution-focused group practitioner
believes that people are competent, and that given a climate where they can
experience their competency, they are able to solve their own problems, enabling
them to live a richer life. From the beginning, the group facilitator sets a tone
of focusing on solutions (Metcalf, 1998) in which group members are given an
opportunity to describe their problems briefly. A facilitator might begin a new
group by requesting, “I would like each of you to introduce yourself. As you do,
give us a brief idea as to why you are here and tell us what you would like for us
to know about you.” Facilitators help members to keep the problem external in
conversations, which tends to be a relief because it gives members an opportunity
to see themselves as less problem-saturated. It is the facilitator’s role to create
opportunities for the members to view themselves as being resourceful. Because
SFBT is designed to be brief, the leader has the task of keeping group members on
a solution track rather than a problem track, which helps members to move in a
positive direction.
The group leader works with members in developing well-formed goals as
soon as possible. Leaders concentrate on small, realistic, achievable changes that
may lead to additional positive outcomes. Because success tends to build upon
itself, modest goals are viewed as the beginning of change. Questions used to assist
members in formulating clear goals might include “What will be different in your
life when each of your problems is solved?” and “What will be going on in the
future that will tell you and the rest of us in the group that things are better for
you?” Sometimes members talk about what others will be doing or not doing and
forget to pay attention to their own goals or behavior. At times such as this they
can be asked, “And what about yourself? What will you be doing differently in that
picture? As a result of your doing things differently, how would you imagine oth-
ers responding to you?”
The facilitator asks members about times when their problems were not present
or when the problems were less severe. The members are assisted in exploring these
exceptions, and special emphasis is placed on what they did to make these events
happen. The participants engage in identifying exceptions with each other. This
improves the group process and promotes a solution focus, which can become quite
powerful. Exceptions are real events that take place outside of the problem context.
In individual counseling, only the therapist and the client are observers of compe-
tency. An advantage of group counseling is that the audience widens and more input
is possible (Metcalf, 1998).
The art of questioning is a main intervention used in solution-focused groups.
Questions are asked from a position of respect, genuine curiosity, sincere interest,
and openness. Group leaders use questions such as these that presuppose change
and remain goal-directed and future-oriented: “What did you do and what has
changed since last time?” or “What did you notice that went better?” Other group
members are encouraged to respond along with the group leader to promote group
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P o s T m o d E R N A P P R o A C H E s 381
interaction. Facilitators may pose questions like these: “Someday, when the prob-
lems that brought you to this group are less problematic to you, what will you be
doing?” “As each of you listened to others today, is there someone in our group who
could be a source of encouragement for you to do something different?” The leader
is attempting to help the members identify exceptions and begin to recognize per-
sonal resiliency and competency. Creating a group context in which the members
are able to learn more about their personal abilities is key to members learning to
resolve their own concerns.
Solution-focused group counseling offers a great deal of promise for practitio-
ners who want a practical and time-effective approach to interventions in school
settings. As a cooperative approach, SFBT shifts the focus from what’s wrong in stu-
dents’ lives to what’s working for them (Murphy, 2015; Sklare, 2005). Rather than
being a cookbook of techniques for removing students’ problems, this approach
offers school counselors a collaborative framework aimed at achieving small, con-
crete changes that enable students to discover a more productive direction. This
model has much to offer to school counselors who are responsible for serving large
caseloads of students in a K–12 school system. For a more detailed discussion of
SFBT in groups, see Corey (2016, chap. 16).
DAVID EPSTON (b. 1944) is one of the developers of narra-
tive therapy. He is a director of the Family Therapy Centre
in Auckland, New Zealand. He is an international traveler,
presenting lectures and workshops in Australia, Europe,
and North America. He is a coauthor of Narrative Means
to Therapeutic Ends (White & Epston, 1990) and Playful
Approaches to Serious Problems: Narrative Therapy With Children
and Their Families (Freeman, Epston, & Lobovits, 1997). He
is well known for his work with persons affected by eating
disorders and was a coauthor of Biting the Hand That Starves
You (Maisel, Epston, & Borden, 2004).
David Epston
Co
ur
te
sy
o
f D
av
id
E
ps
to
n
MICHAEL WHITE (1949–2008) was the cofounder, with
David Epston, of the narrative therapy movement.
He founded the Dulwich Centre in Adelaide, Austra-
lia, and his work with families and communities has
attracted widespread international interest. Among
his many books are Narrative Means to Therapeutic Ends
(White & Epston, 1990), Reauthoring Lives: Interviews
and Essays (1995), Narrative of Therapists’ Lives (1997),
and Maps of Narrative Practice (2007). Michael White
died in April 2008 while visiting San Diego for a teach-
ing workshop.
Michael White
Co
ur
te
sy
o
f C
he
ry
l W
hi
te
, D
ul
w
ic
h
Ce
nt
re
,
A
de
la
id
e,
A
us
tr
al
ia
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382 C H A P T E R T H I R T E E N
Narrative Therapy
Introduction
Of all the social constructionists, Michael White and David Epston (1990) are best
known for their use of narrative in therapy. According to White (1992), individu-
als construct the meaning of life in interpretive stories, which are then treated as
“truth.” Because of the power of dominant culture narratives, individuals tend to
internalize the messages from these dominant discourses, which often work against
the life opportunity of the individual.
Adopting a postmodern, narrative, social constructionist view sheds light on
how power, knowledge, and “truth” are negotiated in families and other social and
cultural contexts (Freedman & Combs, 1996). Narrative therapy is a strengths-based
approach that emphasizes collaboration between client and therapist to help clients
view themselves as empowered and living the way they want (Rice, 2015).
Key Concepts
The key concepts and therapeutic process sections are adapted from sev-
eral different works, but primarily from these sources: Winslade and Monk (2007),
Monk (1997), Winslade, Crocket, and Monk (1997), McKenzie and Monk (1997),
and Freedman and Combs (1996).
Focus of Narrative Therapy The narrative approach involves adopting a shift
in focus from most traditional theories. Therapists are encouraged to establish a
collaborative approach with a special interest in listening respectfully to clients’ stories;
to search for times in clients’ lives when they were resourceful; to use questions as a
way to engage clients and facilitate their exploration; to avoid diagnosing and labeling
clients or accepting a totalizing description based on a problem; to assist clients in
mapping the influence a problem has had on their lives; and to assist clients in
separating themselves from the dominant stories they have internalized so that space
can be opened for the creation of alternative life stories (Freedman & Combs, 1996).
The Role of Stories One of the theoretical underpinnings of narrative therapy
is the notion that problems are manufactured in social, cultural, and political
contexts. We live our lives by the stories we tell about ourselves and that others tell
about us. Our stories shape reality in that they construct and constitute what we see,
feel, and do. The stories we live by grow out of conversations in a social and cultural
context. Change occurs by exploring how language is used to create and maintain
problems (Rice, 2015). Therapy clients have vivid stories to recount. When stories
are changed, not only is the person telling the story changed but the therapist who
is privileged to be a part of this unfolding process is also changed (Monk, 1997).
Listening With an Open Mind All social constructionist theories emphasize listening
to clients without judgment or blame, affirming and valuing them. Narrative
practice goes further in deconstructing the systems of normalizing judgment that
are found in medical, psychological, and educational discourse. Normalizing judgment
is any kind of judgment that locates a person on a normal curve and is used to assess
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P o s T m o d E R N A P P R o A C H E s 383
intelligence, mental health, or normal behavior. Because these kinds of judgments
claim to be objective measures, they are difficult for individuals to resist and usually
are internalized. Narrative therapists argue that suspending personal judgment is
of little value if you participate in normalizing judgment. Deconstruction involves
turning the tables and asking what clients think of the judgments they have been
assigned. Narrative practitioners might be said to invite people to pass judgment on
the judgments that have been working them over. Narrative therapists help clients
modify their painful beliefs, values, and interpretations as clients create meaning and
new possibilities from the stories they share. Therapists do not impose their value
system, and interpretations flow from clients’ stories rather than from a preconceived
and ultimately imposed theory of importance and value.
Narrative therapists strive to listen to the problem-saturated story of the client
without getting stuck. Therapists stay alert for details that give evidence of the cli-
ent’s competence in taking stands against oppressive problems. Winslade and Monk
(2007) maintain that the therapist believes the client’s abilities, talents, positive
intentions, and life experiences can be the catalysts for new possibilities for action.
The narrative therapist demonstrates faith that these inner resources and competen-
cies can be identified, even when the client is having difficulty seeing them.
During the narrative conversation, attention is given to avoiding totalizing lan-
guage, which reduces the complexity of the individual by assigning an all-embracing,
single description to the essence of the person. Therapists begin to separate the per-
son from the problem in their mind as they listen and respond (Winslade & Monk,
2007). This is called double listening.
The narrative perspective focuses on the capacity of humans for creative and
imaginative thought, which is often found in their resistance to dominant discourse.
Narrative practitioners do not assume that they know more about the lives of clients
than their clients do. Clients are the primary interpreters of their own experiences.
People are viewed as active agents who are able to derive meaning from their expe-
riential world, and they are encouraged to join with others who might share in the
development of a counter story.
The Therapeutic Process
This brief overview of the steps in the narrative therapeutic process illustrates the
structure of the narrative approach (O’Hanlon, 1994, pp. 25–26):
�� Collaborate with the client to come up with a mutually acceptable
name for the problem.
�� Personify the problem and attribute oppressive intentions and tactics
to it.
�� Investigate how the problem has been disrupting, dominating, or dis-
couraging to the client.
�� Invite the client to see his or her story from a different perspective by
inquiring into alternative meanings for events.
�� Discover moments when the client wasn’t dominated or discouraged by
the problem by searching for exceptions to the problem.
�� Find historical evidence to bolster a new view of the client as competent
enough to have stood up to, defeated, or escaped from the dominance
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384 C H A P T E R T H I R T E E N
or oppression of the problem. (At this phase the person’s identity and
life story begin to be rewritten.)
�� Ask the client to speculate about what kind of future could be expected
from the strong, competent person who is emerging. As the client
becomes free of problem-saturated stories of the past, he or she can
envision and plan for a less problematic future.
�� Find or create an audience for perceiving and supporting the new story.
It is not enough to recite a counter story. The client needs to live the
counter story outside of therapy. Because the person’s problem initially
developed in a social context, it is essential to involve the social environ-
ment in supporting the new life story that has emerged in the conversa-
tions with the therapist.
Winslade and Monk (2007) stress that narrative conversations do not follow the
linear progression described here; it is better to think of these steps in terms of cycli-
cal progression containing the following elements:
�� Move problem stories toward externalized descriptions of problems
�� Map the effects of a problem on the individual
�� Invite the individual to evaluate the problem and its effects
�� Listen to signs of strength and competence in an individual’s problem-
saturated stories
�� Build a new story of competence and document these achievements
Therapy Goals A general goal of narrative therapy is to invite people to describe
their experience in new and fresh language. In doing this, they open new vistas
of what is possible. This new language enables clients to develop new meanings
for problematic thoughts, feelings, and behaviors (Freedman & Combs, 1996).
Narrative therapy almost always includes an awareness of the impact of various
aspects of dominant culture on human life. Narrative practitioners seek to enlarge
the perspective and facilitate the discovery or creation of new options that are
unique to the people they see.
Therapist’s Function and Role Narrative therapists are active facilitators. The
concepts of care, interest, respectful curiosity, openness, empathy, contact, and
even fascination are seen as a relational necessity. The not-knowing position, which
allows therapists to follow, affirm, and be guided by the stories of their clients,
creates participant-observer and process-facilitator roles for the therapist and
integrates therapy with a postmodern view of human inquiry.
A main task of the therapist is to help clients construct a preferred story line.
The narrative therapist adopts a stance characterized by respectful curiosity and
works with clients to explore both the impact of the problem on them and what
they are doing to reduce the effects of the problem (Winslade & Monk, 2007). One
of the main functions of the therapist is to ask questions of clients and, based on the
answers, to generate further questions.
White and Epston (1990) start with an exploration of the client in relation to
the presenting problem. It is not uncommon for clients to present initial stories in
which they and the problem are fused, as if one and the same. White uses questions
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P o s T m o d E R N A P P R o A C H E s 385
aimed at separating the problem from the people affected by the problem. This shift
in language begins the deconstruction of the original narrative in which the person
and the problem were fused; now the problem is objectified as external to the client.
Like the solution-focused therapist, the narrative therapist assumes the client
is the expert when it comes to what he or she wants in life. The narrative therapist
tends to avoid using language that embodies diagnosis, assessment, treatment, and
intervention. Functions such as diagnosis and assessment often grant priority to
the practitioner’s “truth” over clients’ knowledge about their own lives. The nar-
rative approach gives emphasis to understanding clients’ lived experiences and de-
emphasizes efforts to predict, interpret, and pathologize.
Monk (1997) emphasizes that narrative therapy will vary with each client
because each person is unique. For Monk, narrative conversations are based on a
way of being, and if narrative counseling “is seen as a formula or used as a recipe,
clients will have the experience of having things done to them and feel left out of the
conversation” (p. 24).
The Therapeutic Relationship Narrative therapists place great importance
on the values and ethical commitments a therapist brings to the therapy venture. Some
of these attitudes include optimism and respect, curiosity and persistence, valuing
the client’s knowledge, and creating a special kind of relationship characterized by a
real power-sharing dialogue (Winslade & Monk, 2007). Collaboration, compassion,
reflection, and discovery characterize the therapeutic relationship. The strengths-based
and future-focused nature of narrative therapy lends itself to a more collaborative
relationship than problem-based approaches that emphasize the therapist as the
expert in the relationship (Rice, 2015). If this relationship is to be truly collaborative,
the therapist needs to be aware of how power manifests itself in his or her professional
practice. This does not mean that the therapist does not have authority as a professional.
He or she uses this authority, however, by treating clients as experts in their own lives.
Winslade, Crocket, and Monk (1997) describe this collaboration as coauthor-
ing or sharing authority. Clients function as authors when they have the authority
to speak on their own behalf. In the narrative approach, the therapist-as-expert is
replaced by the client-as-expert. This notion challenges the stance of the therapist as
being an all-wise and all-knowing expert.
Clients are often stuck in a pattern of living a problem-saturated story that does
not work. When a client has a limited perception of his or her capacities due to being
saturated in problem thinking, it is the job of the therapist to elicit other strength-
related stories to modify the client’s perception. The therapist assists the client in
this pursuit by entering into a dialogue and asking questions in an effort to elicit
the perspectives, resources, and unique experiences of the client. The past is history,
but it sometimes provides a foundation for understanding and discovering news
of differences or unique outcomes that will make a difference. The history of the
problem often dominates understanding, but there is another history that narrative
therapists argue should not be neglected. It is the history of the counter story to the
problem story, which is constructed in conversation and becomes the foundation
for a different future. The narrative therapist supplies the optimism and sometimes
a process, but the client generates what is possible and contributes the movement
that actualizes it.
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386 C H A P T E R T H I R T E E N
Application: Therapeutic Techniques and Procedures
The effective application of narrative therapy is more dependent on thera-
pists’ attitudes or perspectives than on techniques. In the practice of narrative ther-
apy, there is no recipe, no set agenda, and no formula that the therapist can follow
to assure positive results (Drewery & Winslade, 1997). When externalizing ques-
tions are approached mainly as a technique, the intervention will be shallow, forced,
and unlikely to produce significant therapeutic effects (Freedman & Combs, 1996;
O’Hanlon, 1994).
Narrative therapists are in agreement with Carl Rogers on the importance of the
therapist’s way of being rather than being technique driven. A narrative approach to
counseling is more than the application of skills; it is based on the therapist’s per-
sonal characteristics that create a climate that encourages clients to see their stories
from different perspectives. Narrative therapists emphasize their willingness to see
beyond dominant cultural norms and to appreciate clients’ differences. However, a
series of “maps” of narrative conversational trajectories can help give structure and
direction to a therapeutic conversation (White, 2007).
Questions . . . and More Questions The questions narrative therapists ask may
seem embedded in a unique conversation, part of a dialogue about earlier dialogues,
a discovery of unique events, or an exploration of dominant culture processes and
imperatives. Whatever the purpose, the questions are often circular, or relational, and
they seek to empower clients in new ways. To use Gregory Bateson’s (1972) famous
phrase, they are questions in search of a difference that will make a difference.
Narrative therapists use questions as a way to generate experience rather than to
gather information. The aim of questioning is to progressively discover or construct
the client’s experience so that the client has a sense of a preferred direction. Ques-
tions are always asked from a position of respect, curiosity, and openness. Therapists
ask questions from a not-knowing position, meaning that they do not pose ques-
tions that they think they already know the answers to.
Through the process of asking questions, therapists provide clients with an
opportunity to explore various dimensions of their life situations. This question-
ing process helps bring out the unstated cultural assumptions that contribute to
the original construction of the problem. The therapist is interested in finding out
how the problems first became evident, and how they have affected clients’ views of
themselves (Monk, 1997). Narrative therapists attempt to engage people in decon-
structing problem-saturated stories, identifying preferred directions, and creating
alternative stories that support these preferred directions. For a more complete dis-
cussion of the use of questions in narrative therapy, see Madigan (2011).
Externalization and Deconstruction Narrative therapists believe it is not the
person that is the problem, but the problem that is the problem (White, 1989).
These problems often are products of the cultural world or of the power relations in
which this world is located. Living life means relating to problems, not being fused
with them. Narrative therapists help clients deconstruct these problematic stories
by disassembling the taken-for-granted assumptions that are made about an event,
which then opens alternative possibilities for living.
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P o s T m o d E R N A P P R o A C H E s 387
Externalization is one process for deconstructing the power of a narrative. This
process separates the person from identification with the problem. When clients
view themselves as “being” the problem, they are limited in the ways they can effec-
tively deal with the problem. When clients experience the problem as being located
outside of themselves, they create a relationship with the problem. For example,
there is quite a difference between labeling someone an alcoholic and indicating
that alcohol has invaded his or her life. Separating the problem from the individual
facilitates hope and enables clients to take a stand against specific story lines, such
as self-blame. By understanding the cultural invitations to blame oneself, clients can
deconstruct this story line and generate a more positive, healing story.
The method used to separate the person from the problem is referred to as exter-
nalizing conversation, which opens up space for new stories to emerge. This method
is particularly useful when people have internalized diagnoses and labels that have
not been validating or empowering of the change process (Bertolino & O’Hanlon,
2002). externalizing conversations counteract oppressive, problem-saturated sto-
ries and empower clients to feel competent to handle the problems they face. Two
stages of structuring externalizing conversations are (1) to map the influence of the
problem in the person’s life, and (2) to map the influence of the person’s life back on
the problem (McKenzie & Monk, 1997).
Mapping the influence of the problem on the person generates a great deal of
useful information and often results in people feeling less shamed and blamed.
People feel listened to and understood when the problem’s influences are explored
in a systematic fashion. A common question is, “When did this problem first
appear in your life?” When this mapping is done carefully, it lays the foundation
for coauthoring a new story line for the client. Often clients feel outraged when
they see for the first time how much the problem is affecting them. The job of
the therapist is to assist clients in tracing the problem from when it originated to
the present. Therapists may put a future twist on the problem by asking, “If the
problem were to continue for a month (or any time period), what would this mean
for you?” This question can motivate the client to join with the therapist in com-
bating the impact of the problem’s effects. Other useful questions are “To what
extent has this problem influenced your life?” and “How deeply has this problem
affected you?”
It is important to identify instances when the problem did not completely dom-
inate a client’s life. This kind of mapping can help the client who is disillusioned
by the problem see some hope for a different kind of life. Therapists look for these
“sparkling moments” as they engage in externalizing conversations with clients
(White & Epston, 1990).
The case of Brandon illustrates an externalizing conversation. Brandon says
that he gets angry far too much, especially when he feels that his wife is criticizing
him unjustly: “I just flare! I pop off, get upset, fight back. Later, I wish I hadn’t, but
it’s too late. I’ve messed up again.” Questions about how his anger occurs, complete
with specific examples and events, can help chart the influence of the problem. How-
ever, it is questions like the ones that follow that externalize the problem: “What is
the mission of the anger, and how does it recruit you into this mission?” “How does
the anger get you, and how does it trick you into letting it become so powerful?”
“What does the anger require of you, and what happens to you when you meet its
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388 C H A P T E R T H I R T E E N
requirements?” “What cultural supports (in your family/community/world) have
shaped the role that anger plays for you?”
Search for Unique Outcomes In the narrative approach, externalizing questions
are followed by questions searching for unique outcomes. The therapist talks to
the client about moments of choice or success regarding the problem. This is done
by selecting for attention any experience that stands apart from the problem story,
regardless of how insignificant it might seem to the client. The therapist may ask:
“Was there ever a time in which anger wanted to take you over, and you resisted?
What was that like for you? How did you do it?” These questions are aimed at
highlighting moments when the problem has not occurred or when the problem
has been dealt with successfully. Unique outcomes can often be found in the past
or the present, but they can also be hypothesized for the future: “What form would
standing up against your anger take?” Exploring questions such as these enables
clients to see that change is possible. Linking a series of such unique outcomes
together starts to form a counter story. It is within the account of unique outcomes
that a gateway is provided for alternative versions of a person’s life (White, 1992).
Following the description of a unique outcome, White (1992) suggests posing
questions, both direct and indirect, that lead to the elaboration of preferred identity
stories:
�� What do you think this tells me about what you have wanted for your
life and about what you have been trying for in your life?
�� How do you think knowing this has affected my view of you as a person?
�� Of all those people who have known you, who would be least surprised
that you have been able to take this step in addressing your problem’s
influence in your life?
�� What actions might you commit yourself to if you were to more fully
embrace this knowledge of who you are? (p. 133)
The development of unique outcome stories into solution stories is facilitated
by what Epston and White (1992) call “circulation questions”:
�� Now that you have reached this point in life, who else should know
about it?
�� I guess there are a number of people who have an outdated view of
who you are as a person. What ideas do you have about updating these
views?
�� If other people seek therapy for the same reasons you did, can I share
with them any of the important discoveries you have made? (p. 23)
These questions are not asked in a barrage-like manner. Questioning is an integral
part of the context of the narrative conversation, and each question is sensitively
attuned to the responses brought out by the previous question (White, 1992).
McKenzie and Monk (1997) suggest that therapists seek permission from the
client before asking a series of questions. By letting a client know that they do not
have answers to the questions they raise, therapists are putting the client in control
of the therapeutic process. Asking permission of the client to use persistent ques-
tioning tends to minimize the risk of inadvertently pressuring the client.
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P o s T m o d E R N A P P R o A C H E s 389
Alternative Stories and Reauthoring Constructing counter stories goes hand
in hand with deconstruction, and the narrative therapist listens for openings to
counter stories. People can continually and actively reauthor their lives, and narrative
therapists invite clients to author alternative stories through “unique outcomes”;
these events could not be predicted from listening to the dominant problem-
saturated story and are not included in any narrative about the person. The narrative
therapist asks for openings: “Have you ever been able to escape the influence of the
problem?” The therapist listens for clues to competence in the midst of a problematic
story and builds a story of competence around it. Madigan (2011) suggests that a
person’s life story is probably much more interesting than the story being told. He
maintains a therapist’s main task is “to help people to remember, reclaim and reinvent
a richer, thicker, and more meaningful alternative story” (p. 159).
A turning point in the narrative interview comes when clients make the choice
of whether to continue to live by a problem-saturated story or to state a preference
for an alternative story (Winslade & Monk, 2007). Through the use of unique pos-
sibility questions, the therapist moves the focus into the future. For example: “Given
what you have learned about yourself, what is the next step you might take?” “When
you are acting from your preferred identity, what actions will it lead you to do more
of?” Such questions encourage people to reflect upon what they have presently
achieved and what their next steps might be.
White and Epston’s (1990) inquiry into unique outcomes is similar to the excep-
tion questions of solution-focused therapists. Both seek to build on the competence
already present in the person. The development of alternative stories, or narratives,
is an enactment of ultimate hope: Today is the first day of the rest of your life.
Refer to Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 11) for two
concrete examples of a narrative approach to working with Ruth from the perspec-
tives of Dr. Gerald Monk and Dr. John Winslade.
Documenting the Evidence Narrative practitioners believe that new stories take
hold only when there is an audience to appreciate and support them. Gaining an
audience for the news that change is taking place needs to occur if alternative stories
are to stay alive, and an appreciative audience to new developments is consciously
sought.
One technique for consolidating the gains a client makes involves a therapist
writing letters to the person. Narrative therapists have pioneered the development of
therapeutic letter writing. These letters that the therapist writes provide a record of
the session and may include an externalizing description of the problem and its influ-
ence on the client, as well as an account of the client’s strengths and abilities that are
identified in a session. Letters can be read again at different times, and the story that
they are part of can be reinspired. The letter highlights the struggle the client has had
with the problem and draws distinctions between the problem-saturated story and
the developing new and preferred story (McKenzie & Monk, 1997).
Epston has developed a special facility for carrying on therapeutic dialogues
between sessions through the use of letters (White & Epston, 1990). His letters may
be long, chronicling the process of the interview and the agreements reached, or
short, highlighting a meaning or understanding reached in the session and ask-
ing a question that has occurred to him since the end of the previous therapy visit.
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390 C H A P T E R T H I R T E E N
Usually they include as many direct quotations from what the client said as possible.
These letters are used to encourage clients, noting what they said about their own
accomplishments in relation to handling problems or speculating on the meaning
of their accomplishments for others in their community. Letters documenting the
changes clients have achieved tend to strengthen the significance of the changes,
both for the client and for others in the client’s life.
Narrative letters reinforce the importance of carrying what is being learned in the
therapy office into everyday life. The message conveyed is that participating fully in
the world is more important than being in the therapy office. In an informal survey
of the perceptions of the value of narrative letters by past clients, the average worth of
a letter was equal to more than three individual sessions (Nylund & Thomas, 1994).
This finding is consistent with McKenzie and Monk’s (1997) statement: “Some nar-
rative counselors have suggested that a well-composed letter following a therapy ses-
sion or preceding another can be equal to about five regular sessions” (p. 113).
Application to Group Counseling Many of the techniques described
in this chapter can be applied to group counseling. Winslade and Monk (2007)
claim that the narrative emphasis on creating an appreciative audience for new
developments in an individual’s life lends itself to group counseling. They state:
“Groups provide a ready-made community of concern and many opportunities
for the kind of interaction that opens possibilities for new ways of living. New
identities can be rehearsed and tried out into a wider world” (p. 135). They give
several examples of working in a narrative way with groups in schools: getting back
on track in schoolwork; an adventure-based program; an anger management group;
and a grief counseling group. For a detailed description of these narrative groups,
see Winslade and Monk (2007, chap. 5).
Postmodern Approaches From a Multicultural Perspective
Strengths From a Diversity Perspective
Social constructionism is congruent with the philosophy of multicultur-
alism. One of the problems that culturally diverse clients often experience is the
expectation that they should conform their lives to the truths and reality of the
dominant society of which they are a part. With the emphasis on multiple realities
and the assumption that what is perceived to be a truth is the product of social con-
struction, the postmodern approaches are a good fit with diverse worldviews.
The social constructionist approach to therapy provides clients with a frame-
work to think about their thinking and to determine the impact stories have on
what they do. Clients are encouraged to explore how their realities are being con-
structed out of cultural discourse and the consequences that follow from such con-
structions. Within the framework of their cultural values and worldview, clients
can explore their beliefs and provide their own reinterpretations of significant life
events. The practitioner with a social constructionist perspective can guide clients in
a manner that respects their underlying values. This dimension is especially impor-
tant in those cases where counselors are from a different cultural background or do
not share the same worldview as their clients.
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P o s T m o d E R N A P P R o A C H E s 391
Narrative therapy is grounded in a sociocultural context, which makes this
approach especially relevant for counseling culturally diverse clients. Narrative ther-
apists operate on the premise that problems are identified within social, cultural,
political, and relational contexts rather than existing within individuals. They are
very much concerned with considering the specifications of gender, ethnicity, race,
disability, sexual orientation, social class, and spirituality and religion as therapeutic
issues. Furthermore, therapy becomes a place to reauthor the social constructions
and identity narratives that clients are finding problematic.
Narrative therapy is a relational and anti-individualistic practice. Michael White
believes that to address a person’s struggles in therapy without a relational and con-
textual understanding of his or her story is entirely absurd (as cited in Madigan,
2011). Narrative therapists concentrate on problem stories that dominate and sub-
jugate at the personal, social, and cultural levels. The sociopolitical conceptualiza-
tion of problems sheds light on those cultural notions and practices that produce
dominant and oppressive narratives. From this orientation, practitioners take apart
the cultural assumptions that are a part of a client’s problem situation. People are
able to come to an understanding of how oppressive social practices have affected
them. This awareness can lead to a new perspective on dominant themes of oppres-
sion that have been such an integral part of a client’s story, and with this cultural
awareness new stories can be generated.
In their discussion of the multicultural influences on clients, Bertolino and
O’Hanlon (2002) approach clients without a preconceived notion about their expe-
rience and learn from their clients about their experiential world. Bertolino and
O’Hanlon practice multicultural curiosity by listening respectfully to their clients,
who become their best teachers. Here are some questions these authors suggest as a
way to more fully understand multicultural influences on a client:
�� Tell me more about the influence that [some aspect of your culture] has
played in your life.
�� What can you share with me about your background that will enable
me to more fully understand you?
�� What challenges have you faced growing up in your culture?
�� What, if anything, about your background has been difficult for you?
�� How have you been able to draw on strengths and resources from your
culture? What resources can you draw from in times of need?
Questions such as these can shed light on specific cultural influences that have
been sources of support or that contributed to a client’s problem.
Shortcomings From a Diversity Perspective
A potential shortcoming of the postmodern approaches pertains to the not-
knowing stance the therapist assumes, along with the assumption of the client-
as-expert. Individuals from many different cultural groups tend to elevate the
professional as the expert who will offer direction and solutions for the person
seeking help. If the therapist is telling the client, “I am not really an expert; you
are the expert; I trust in your resources for you to find solutions to your prob-
lems,” then this may engender lack of confidence in the therapist. To avoid this
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392 C H A P T E R T H I R T E E N
situation, the therapist using a solution-focused or a narrative orientation needs
to convey to clients that he or she has expertise in the process of therapy but
clients are the experts in knowing what they want in their lives. The postmodern
approaches stress being transparent with clients and honoring their hopes and
expectations in therapy. This emphasis creates a context for providing culturally
responsive services.
I operate from an integrative perspective by combining concepts and techniques from the solution-focused
and narrative approaches. From this framework, I am
philosophically opposed to assessment and diagnosis
using the DSM-5 model, and I do not begin therapy
with a formal assessment. Instead, I engage Stan in col-
laborative conversations centered on change, compe-
tence, preferences, possibilities, and ideas for making
changes in the future.
I begin my work with Stan by inviting him to tell
me about the concerns that brought him to therapy
and what he expects to accomplish in his sessions. I
also provide Stan with a brief orientation of some of
the basic ideas that guide my practice and describe
my view of counseling as a collaborative partnership
in which he is the senior partner. Stan is somewhat
surprised by this because he expected that I was the
person with the experience and expertise. He informs
me that he has very little confidence in knowing how
to proceed with his life, especially since he has “messed
up” so often. I am aware that he has self-doubts when
it comes to assuming the role of senior partner. How-
ever, I work to demystify the therapeutic process and
establish a collaborative relationship, conveying to
Stan that he is in charge of the direction his therapy
will take. I also promise to explore the undermining
effects of the self-doubts in his life and how he has
managed to live life in spite of these.
Soon after this orientation to how therapy works,
I inquire about some specific goals that Stan would
like to reach through the therapy sessions. Stan gives
clear signs that he is willing and eager to change.
However, he adds that he has become convinced that
he suffers from low self-esteem. As he tells me more
about how self-doubts cripple him regularly and lead
to a negative evaluation of himself as “messed up,” I
begin to externalize the idea of self-doubts and inquire
into the history of their appearance in his life. I also
carefully map the effects of self-doubts in his life. Then
I start to focus Stan on looking for exceptions to the
self-doubts. I pose an exception question (solution-
focused therapy): “What is different about the contexts
or times when you have not experienced self-doubts?”
Stan is able to identify some positive characteristics:
his courage, determination, and willingness to try
new things in spite of his self-doubts, and his gift for
working with children. Stan knows what he wants out
of therapy and has clear goals: to achieve his educa-
tional goals, to enhance his belief in himself, to relate
to women without fear, and to feel more joy instead of
sadness and anxiety. I invite Stan to talk more about
how he has managed to make the gains he has in spite
of struggling with the problem of self-doubt.
I allow Stan to share his problem-saturated story,
but I do not get stuck in this narrative. I invite Stan
to think of his problems as external to the core of his
selfhood. I help him to notice the cultural forces that
have recruited him into a story of thinking less about
himself. Even during the early sessions, I encourage
Stan to separate his being from his problems by pos-
ing questions that externalize his problem.
Although Stan presents several problem areas
that are of concern to him, I work with him on identi-
fying one particular problem. Stan says he is depressed
a great deal of the time, and he worries that his depres-
sion might someday overwhelm him. After listening to
Stan’s fears and concerns, I ask Stan the miracle ques-
tion (solution-focused technique): “Let’s suppose that
a miracle were to happen while you are asleep tonight.
When you wake up tomorrow, the problems you are
mentioning are gone. What would be the signs to you
that this miracle actually occurred and that your prob-
lems were solved? How would your life be different?”
With this intervention, I am shifting the focus from
Postmodern Approaches Applied to the Case of Stan
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P o s T m o d E R N A P P R o A C H E s 393
talking about problems to talking about solutions.
I explain to Stan that much of his therapy will deal
with finding both present and future solutions rather
than dwelling on past problems. Together we engage
in a conversation that features change-talk rather than
problem-talk.
To a great extent, Stan has linked his identity
story with his problems, especially depression. He
doesn’t think of his problems as being separate from
himself. I want Stan to realize that he personally is
not his problem, but instead that the problem is the
problem. When I ask Stan to give a name to his prob-
lem, he eventually comes up with “Disabling depres-
sion!” He then relates how his depression has kept
him from functioning the way he would like in many
areas of his life. I then use externalizing questions (nar-
rative technique) as a way to separate Stan from his
problem: “How long has depression gotten the best of
you?” “What has depression cost you?” “What conclu-
sions about yourself does it talk you into?” “What do
you think of what it has been doing to mess up your
life?” “Have there been times when you stood up to
depression and did not let it win?” Of course, I briefly
explain to him what I am doing by using externalizing
language, lest he think this is a strange way to counsel.
I talk more about the advantages of engaging in exter-
nalizing conversations. I also talk with Stan about the
importance of mapping the effects of the problem
on his life. This process involves exploring how long
the problem has been around, the extent to which the
problem has influenced various aspects of his life, and
how deeply the problem continues to affect him.
As the sessions progress, there is a collaborative
effort aimed at investigating how the problem has been
a disrupting, dominating, and discouraging influence.
Stan comes to view his story from a different perspec-
tive. I continue talking with Stan about those moments
when he has not been dominated or discouraged by
depression and anxiety and continue to search for
exceptions to these problematic experiences. Stan and
I participate in conversations about unique outcomes,
or occasions when he has demonstrated courage and
persistence in the face of discouraging events. Some of
these “sparkling moments” include Stan’s accomplish-
ments in college, volunteer work with children, progress
in curbing his tendencies to abuse alcohol, willingness
to challenge his fears and make new acquaintances,
talking back to self-defeating internal messages, accom-
plishments in securing employment, and his willing-
ness to create a vision of a productive future.
With my help, Stan accumulates evidence from
his past to bolster a new view of himself as competent
enough to have escaped from the dominance of prob-
lematic stories. At this phase in his therapy, Stan makes
a decision to create an alternative narrative. Several ses-
sions are devoted to reauthoring Stan’s story in ways
that are lively, creative, and colorful. Along with the
process of creating an alternative story, I explore with
Stan the possibilities of recruiting an audience who will
reinforce his positive changes. I ask, “Who do you know
who would be least surprised to hear of your recent
changes, and what would this person know about you
that would lead to him or her not being so surprised?”
Stan identifies one of his early teachers who served as a
mentor to him and who believed in him when Stan had
little belief in himself. Some therapy time is devoted to
discussing how new stories take root only when there is
an audience to appreciate them.
After five therapy sessions, Stan brings up the
matter of termination. At the sixth and final session,
I introduce scaling questions, asking Stan to rate his
degree of improvement on a range of problems we
explored in the past weeks. On a scale of zero to 10,
Stan ranks how he saw himself prior to his first ses-
sion and how he sees himself today on various specific
dimensions (scaling technique). We also talked about
Stan’s goals for his future and what kinds of improve-
ments he will need to make to attain what he wants.
I then give Stan a letter I wrote summarizing both
the problem story and its effects and also the counter
story that we have been developing in therapy. In my
narrative letter, I describe Stan’s determination and
cooperation in his own words and encourage him to
circulate the news of the differences he has brought
about in his life. I also ask some questions that invite
him to develop the new story of identity more fully.
Questions for Reflection
�� As Stan’s therapist, I borrowed key concepts and
techniques common to both solution-focused and
narrative orientations. In your work with Stan,
what specific concepts would you borrow from
each of these approaches? What techniques would
you draw from each of the approaches? What
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possible advantages do you see, if any, in applying
an integration of solution-focused and narrative
models in your work with Stan?
�� What unique values, if any, do you see in work-
ing with Stan from a postmodern perspective as
opposed to working with Stan from the other
therapeutic approaches you’ve studied thus far?
�� I asked many questions of Stan. List some addi-
tional questions you would be particularly inter-
ested in pursuing with Stan.
�� In what ways could you integrate SFBT and narra-
tive therapy with feminist therapy in Stan’s case?
What other therapies might you combine with the
postmodern approaches? What other therapies
would not combine so well with these postmodern
therapies?
�� At this point, you are very familiar with the
themes in Stan’s life. If you were to write a narra-
tive letter that you would then give to Stan, what
would you most want to include? What would you
want to talk to him about regarding his future?
Visit CengageBrain.com or watch the dVd for the
video program on Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes,
session 11 (sFBT) and session 12 (narrative
therapy), for a demonstration of my approach to
counseling stan from this perspective. session 11
illustrates techniques such as identifying excep-
tions, the miracle question, and scaling. session
12 focuses on stan’s work in creating a new story
of his life.
solution-Focused brief therapy
With gwen
T his session begins with Gwen expressing how overwhelmed she is with the number of assign-
ments she has at work.
Gwen: I don’t think I can handle the pressure of these
new assignments.
Therapist: On a scale of zero to 10, where zero is no
pressure and 10 is extreme pressure. Where would
your feeling of pressure be on the scale?
Gwen: 8! I should have just kept quiet and not taken on
any new projects. I always do this to myself. I wish I
could start over and not take on so much. I am miss-
ing out on time with my family and friends because
I have piled the work on so high! I don’t know why
I create so much work for myself. I know people at
work can see that I am on the edge. I am not feeling
good about anything I am doing these days. I know
I’m ruining my reputation because I just can’t get
things done. I am missing in action in my own life.
Therapist: Tell me about some times when you did
not feel this way. What were you doing when
things were getting done that you are not doing
now?
I encourage Gwen to think about some time when
her stress was not so overwhelming and what she did
to better manage her stress. This focus on discovering
Gwen’s strengths puts Gwen in the position of being
the expert on her own life. I am confident that Gwen
has the a capacity to find solutions to her challenges.
Gwen is so accustomed to her story of anxiety and
feeling overwhelmed that it is difficult for her to shift
gears and observe that she is doing several things well
in her life. My interventions are aimed at assisting her
in seeing herself as more than being highly anxious.
Therapist: In the midst of your busy life, you have
remained committed to therapy. I find that very
impressive given your schedule and the number of
obligations you are juggling. I wonder what else
might be going well in your life.
Gwen: I have been arriving at work on time, and that
feels pretty good. Also, I took time for a swimming
lesson even though I was stressed out about getting
my projects done. I must say that I felt so much
better afterward.
Postmodern Approaches Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a postmodern perspective, first using SFBT and then using narrative
therapy, and applying these models to Gwen.
394 C H A P T E R T H I R T E E N
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P o s T m o d E R N A P P R o A C H E s 395
Therapist: If you had a magic wand and could solve
your problem today, how would you know it was
solved? [The miracle question]
Gwen: I would know it was solved if I did not have
a stomach ache, did not triple book meetings,
didn’t have five projects due all at once, felt com-
fortable taking time for relaxation, had time to go
out with friends, and didn’t have stacks of paper
around my house and office just waiting for me to
handle it all.
Therapist: What would you be doing or feeling that
would be different?
Gwen: I would be able to go home at a reasonable
time at after work. I would feel more rested. I
would have healthy and balanced meals, and I
would have more quality time with my husband
and children. At work, I would feel good about the
projects I was finishing, and I would resist taking
on too many projects at the same time.
The miracle question, or the magic wand question
as I call it, is a way to assist Gwen in projecting into the
future to the life she wants to experience. I emphasize
that doing one thing differently could be a significant
step in finding a solution.
Therapist: I invite you to rip up your canvas of anxiety
and create a new portrait of calm in your life by
doing one thing differently. What do you think you
can change this week?
Gwen: I will begin my day with prayer and some
stretching exercises to help me loosen up and to re-
duce my stress level. And I think it is time to resign
from one of the committees I am on now.
Therapist: Those are great choices you are making. I
look forward to hearing how you did when we meet
next week.
I compliment Gwen on the progress she is making,
and in our next session I will follow up on her home-
work. I hope Gwen will discover that the answers she is
seeking reside within herself.
Questions for Reflection
�� What interventions helped Gwen begin to think
more about her resources and strengths than
about her problems?
�� What do you think of the application of the mir-
acle question with Gwen? What steps did Gwen
decide to take as a result of her answer?
�� If you were counseling Gwen and she was unable
to recall any time when the problem did not exist,
how would you move forward with her?
narrative therapy With gwen
Words have the power to heal and transform our lives.
Words also have the power to keep us spiraling down-
ward, accepting a negative story line that perpetuates
feelings of depression, scarcity, fear, anxiety, self-
loathing, and more. Our stories fuel our thoughts and
behaviors, and we must make sure that these stories
are not a source of negative programming that keeps
us stuck. If Gwen is willing to keep a journal and write
about her younger self, I think she will begin to recon-
struct the story of her true self today.
Therapist: Words can become our medicine and our
tool for transformation and healing. I would like
you to use this journal to write about your story
of loneliness. Try to identify when loneliness first
appeared in your life. Let the words present them-
selves in whatever way they come.
Gwen: I think I could write volumes about feeling
unimportant, invisible, and insignificant when I
was a child.
Therapist: Before you begin writing, sit quietly for 5
minutes and connect to your younger self who first
experienced these feelings of loneliness. Give that
part of yourself a name and become a loving com-
panion to that lonely little girl inside of you.
My goal is to help Gwen externalize the problem she is
experiencing and move it outside of herself. As Gwen
separates herself from her problem-saturated story,
she can release the old patterns associated with the old
story and literally rewrite her life to include peace, joy,
and connection.
Gwen writes about staying in the house to avoid
being called names by the kids on her street; being the
odd child in the family and wanting to hide because
she was different; waiting days for her dad to return
home; hiding her precious items in a special box so
they wouldn’t get stolen when the house was broken
into; being the only Black child in the Catholic Church
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Summary and Evaluation
Summary
In social constructionist theory the therapist-as-expert is replaced by the
client-as-expert. Although clients are viewed as experts on their own lives, they are
often stuck in patterns that are not working well for them. Both solution-focused
and narrative therapists enter into dialogues in an effort to elicit the perspectives,
resources, and unique experiences of their clients. The therapeutic endeavor is a
highly collaborative relationship in which the client is the senior partner. The quali-
ties of the therapeutic relationship are at the heart of the effectiveness of both SFBT
and narrative therapy. This has resulted in many therapists giving increased atten-
tion to creating a collaborative relationship with clients. Collaborative therapists
adjust their approach to each client or group instead of requiring clients to adapt to
their approach. Thus therapy may look very different for one client than for another.
The not-knowing position of the therapist has been infused as a key con-
cept of both the solution-focused and narrative therapeutic approaches. The not-
knowing position, which allows therapists to be curious about, affirm, and be
guided by the stories of their clients, creates participant-observer and process-
facilitator roles for the therapist and integrates therapy with a postmodern per-
spective of human inquiry.
Both solution-focused brief therapy and narrative therapy are based on the opti-
mistic assumption that people are healthy, competent, resourceful, and possess the
ability to construct solutions and alternative stories that can enhance their lives. In
SFBT the therapeutic process provides a context whereby individuals focus on creat-
ing solutions rather than talking about their problems. Some common techniques
include the use of miracle questions, exception questions, and scaling questions.
In narrative therapy the therapeutic process attends to the sociocultural context
and feeling like she was under a microscope; and how
she began to stay busy to keep herself safe. I work with
Gwen to help her view her stories through a lens of
compassion, growth, and healing.
As Gwen began to reconstruct her story, she was able
to see that her parents did the best they could. She looked
at the entire cast of her narrative with deeper compassion
and saw that through the challenges of her childhood she
become a strong, creative, resilient woman. From a posi-
tion of adult strength, Gwen began to sooth the lonely
little girl that still resides in her heart. Through writing,
Gwen could see that she was wounded but not broken.
Narrative therapy helped Gwen come closer to a place of
self-love and forgiveness, and her anxiety began to lessen
as she released the repressed emotions that had kept her
isolated and lonely. In her final session, Gwen and I devel-
oped a written “graduation speech” together in which we
formalized the fact that she is no longer a child and has
moved beyond her history.
Questions for Reflection
�� What therapeutic purpose is served when the
therapist helps Gwen separate herself from the
problem?
�� What value do you see in journal writing as a tool
to assist Gwen in reconstructing her story?
�� What is one other technique from narrative ther-
apy that you would want to use with Gwen?
�� How do you experience hearing about Gwen’s sto-
ries of loneliness?
LO13
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
P o s T m o d E R N A P P R o A C H E s 397
wherein clients are assisted in separating themselves from their problems and are
afforded the opportunity of authoring new stories.
Practitioners with solution-focused or narrative orientations tend to engage
clients in conversations that lead to progressive narratives that help clients make
steady gains toward their goals. Therapists often ask clients: “Tell me about times
when your life was going the way you wanted it to.” These conversations illustrate
stories of life worth living. On the basis of these conversations, the power of prob-
lems is taken apart (deconstructed) and new directions and solutions are manifest
and made possible.
Contributions of Postmodern Approaches
Social constructionism, SFBT, and narrative therapy are making many contribu-
tions to the field of psychotherapy. I especially value the optimistic orientation of
these postmodern approaches that rest on the assumptions that people are compe-
tent and can be trusted to use their resources in creating better solutions and more
life-affirming stories. Many postmodern practitioners and writers have found that
clients are able to make significant moves toward building more satisfying lives in a
relatively short period of time (Bertolino & O’Hanlon, 2002; De Jong & Berg, 2013;
de Shazer, 1991; Freedman & Combs, 1996; Hoyt, 2009, 2015; Miller, Hubble, &
Duncan, 1996; O’Hanlon & Weiner-Davis, 2003; Walter & Peller, 1992, 2000; Win-
slade & Monk, 2007).
To its credit, solution-focused therapy is a brief approach, of about five sessions,
that seems to show promising results (de Shazer, 1991). SFBT tends to be very brief,
even among the time-limited therapies. It should be noted that the brevity comes
from the client being in charge of goal setting and determining which issues are of
immediate concern. This differs from many other models in which the therapist
determines the direction therapy should take.
I think the nonpathologizing stance characteristic of practitioners with a social
constructionist, solution-focused, or narrative orientation is a major contribution
to the counseling profession. Rather than dwelling on what is wrong with a person,
these approaches view the client as being competent and resourceful. People cannot
be reduced to a specific problem nor accurately labeled and identified with a disor-
der. Even practitioners who are expected to formulate a diagnosis can learn the value
of a respectful way to relate to clients.
One particular area where the solution-focused approach shows promise is in
group treatment with domestic violence offenders. Lee, Sebold, and Uken (2003)
describe a cutting-edge treatment approach that seems to create effective, positive
change in domestic violence offenders. This approach is dramatically different from
traditional approaches in that there is virtually no emphasis on the presenting prob-
lem of domestic violence. The approach focuses on holding offenders accountable
and responsible for building solutions rather than emphasizing their problems and
deficits. The process described by Lee and colleagues is brief when measured against
traditional program standards, lasting only eight sessions over a 10- to 12-week
period. Lee, Sebold, and Uken report research that indicates a recidivism rate of 16.7%
and completion rates of 92.9%. In contrast, more traditional approaches typically
generate recidivism rates between 40 and 60% and completion rates of less than 50%.
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398 C H A P T E R T H I R T E E N
A major strength of both solution-focused and narrative therapies is the use of
questioning, which is the centerpiece of both approaches. Open-ended questions
about the client’s attitudes, thoughts, feeling, behaviors, and perceptions are one
of the main interventions. Especially useful are future-oriented questions that get
clients thinking about how they are likely to solve potential problems in the future.
Questions can assist clients in developing their story and discovering better ways to
deal with their concerns. Effective questioning can help individuals examine their
story and find new ways to present it.
Limitation and Criticisms of Postmodern Approaches
To effectively practice solution-focused brief therapy, it is essential that therapists
are skilled in brief interventions. Although it may appear that SFBT is simple and
easy to implement, therapists practicing within this framework must be able to
make assessments, assist clients in formulating specific goals, and effectively use
a range of appropriate interventions. Some inexperienced or untrained therapists
may be enamored by the variety of techniques: the miracle question, scaling ques-
tions, the exception question, and externalizing questions. But effective therapy is
not simply a matter of relying on any of these interventions. The attitudes of the
therapist and his or her ability to use questions that are reflective of genuine respect-
ful interest are crucial to the therapeutic process.
McKenzie and Monk (1997) express their concerns over those counselors who
attempt to employ narrative ideas in a mechanistic fashion. They caution that a risk
in describing a map of a narrative orientation lies in the fact that some beginners
will pay more attention to following the map than they will to following the lead of
the client. In such situations, McKenzie and Monk are convinced that mechanically
using techniques will not be effective. They add that although narrative therapy is
based on some simple ideas, it is a mistake to assume that the practice is simple.
Some solution-focused practitioners now acknowledge the problem of relying too
much on a few techniques, and they are placing increased importance on the thera-
peutic relationship and the overall philosophy of the approach (Lipchik, 2002; Mur-
phy, 2015).
Despite these limitations, the postmodern approaches have much to offer prac-
titioners, regardless of their theoretical orientation. Many of the basic concepts and
techniques of both solution-focused brief therapy and narrative therapy can be inte-
grated into the other therapeutic orientations discussed in this book.
Self-Reflection and Discussion Questions
1. Both solution-focused brief therapy and narrative therapy emphasize
viewing the client-as-expert, creating new stories, establishing a collab-
orative therapeutic relationship, discovering resources and strengths of
the client, and separating the problem from the person. What are your
thoughts about these ideas?
2. What key concept are you most drawn to in SFBT? In narrative therapy?
What do you find of interest in this key concept?
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P o s T m o d E R N A P P R o A C H E s 399
3. A SFBT practitioner has many techniques to choose from in helping
clients create their own solutions. Which of these techniques would
you like to become skilled at using?
4. Narrative therapists talk about deconstructing a problem-saturated story
and reauthoring a life-enhancing story. What do you think of this idea?
5. How do the postmodern approaches differ from some of the other
theories you have studied thus far?
Where to Go From Here
Free Podcasts for ACA Members
You can download ACA Podcasts (prerecorded interviews) at www.counseling.org;
click on the Resource button and then the Podcast Series. For Chapter 13, Postmod-
ern Approaches, look for the following:
Interview with Dr. John Murphy on Solution-Focused Counseling in Schools
(Podcast 5)
Lorraine Hedtke, L. & Winslade, J., Remembering Lives, Conversations With the
Dying and Bereaved
Other Resources
Psychotherapy.net is a comprehensive resource for students and professionals that
offers videos and interviews on the postmodern approaches. New video and edito-
rial content is made available monthly. DVDs relevant to this chapter are available
at www.psychotherapy.net and include the following:
Madigan, S. (2002). Narrative Therapy With Children (Child Therapy With
the Experts)
Madigan, S. (1998). Narrative Family Therapy (Family Therapy With the
Experts)
Murphy, J. (2002). Solution-Focused Therapy With Children (Child
Therapy With the Experts)
If you are interested in keeping up to date with the developments in brief ther-
apy, the Journal of Brief Therapy is a useful resource. It is devoted to developments,
innovations, and research related to brief therapy with individuals, couples, families,
and groups. The articles deal with brief therapy related to all theoretical approaches,
but especially to social constructionism, solution-focused therapy, and narrative
therapy. For subscription information, contact:
Springer Publishing Company
www.springerpub.com
Another useful journal is the International Journal of Narrative Therapy and Com-
munity Work. For more information, contact:
Dulwich Centre
http://dulwichcentre.com.au
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400 C H A P T E R T H I R T E E N
Training in Solution-Focused Therapy Approaches
The Solution Focused Institute (SFI) at Texas Wesleyan University was founded in
January 2009 in Fort Worth, Texas, to provide training to mental health practitio-
ners and school teachers and counselors who want to implement a solution-focused
approach in their work. The institute provides training on- and off-site in solution-
focused therapy and offers supervision to individuals and groups. For information
on SFI services, contact:
Solution Focused Institute
www.Solutionfocusedinstitute.com
Change-Focused Practice in Schools (CFPS) was initiated by John Murphy in
2005 to translate psychotherapy research into practical applications in schools and
other settings. CFPS offers international training, supervision, and consultation
on solution-focused/client-directed approaches to helping young people change
in ways that honor their strengths, resources, and feedback. For more information,
contact:
Department of Psychology & Counseling
University of Central Arkansas
www.drjohnmurphy.com
Training in Narrative Therapy
Evanston Family Therapy Institute
www.narrativetherapychicago.com/
Dulwich Centre
www.dulwichcentre.com.au/
Bay Area Family Therapy Training Associates
www.baftta.com
The Houston-Galveston Institute
www.talkhgi.com
Recommended Supplementary Readings
Interviewing for Solutions (De Jong & Berg, 2013) is a
practical text aimed at teaching and learning solu-
tion-focused skills. It is written in a conversational
and informal style and contains many examples to
solidify learning.
Solution-Focused Counseling in Schools (Murphy,
2015) is a clearly written and practical book that
offers efficient strategies for addressing a range of
problems from preschool through high school.
Numerous case examples illustrate the foundations,
tasks, and techniques of solution-focused counsel-
ing. The book also describes how the principles of
client-directed, outcome-informed practice can be
integrated in solution-focused counseling.
Brief Psychotherapies: Principles and Practices (Hoyt,
2009) is an excellent resource for learning more
about brief psychotherapy as it applies to many the-
oretical approaches.
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P o s T m o d E R N A P P R o A C H E s 401
Narrative Means to Therapeutic Ends (White & Epston,
1990) is the most widely known book on narrative
therapy.
Maps of Narrative Practice (White, 2007) is Michael
White’s final book, which brings together much
of his work over several decades in one accessible
volume.
Narrative Therapy (Madigan, 2011) provides an
updated discussion of the theory and therapeutic
process of narrative therapy.
Narrative Counseling in Schools (Winslade & Monk,
2007) is a basic and easy-to-read guide to applying
concepts and techniques of narrative therapy to
school settings.
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403
14Family Systems TherapyCoauthored by James Robert Bitter and Gerald Corey
1. Identify the key figures and major
schools of family therapy.
2. Understand the commonalities
among all models of family
systems therapy.
3. Describe how family systems
therapy is different from individual
therapy.
4. Differentiate the key concepts and
goals associated with each of the
separate schools of family therapy.
5. Identify recent innovations
in family therapy.
6. Understand the multilayered
process of family therapy.
7. Describe the strengths and
shortcomings of family systems
therapy from a diversity
perspective.
8. Identify the contributions and
limitations of the family systems
approaches.
L e a r n i n g O b j e c t i v e s
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404 C H A P T E R F O U R T E E N
Introduction
Although the seeds of a North American family therapy movement were
planted in the 1940s, it was during the 1950s that systemic family therapy began to
take root (Becvar & Becvar, 2012). During the early years of its evolution, working with
families was considered to be a revolutionary approach to treatment. In the 1960s and
1970s, psychodynamic, behavioral, and humanistic approaches (called the first, sec-
ond, and third force, respectively) dominated counseling and psychotherapy. Today,
the various approaches to family systems represent a paradigm shift that we might
even call the “fourth force.” Family systems therapy is represented by a variety of theo-
ries and approaches, all of which focus on the relational aspects of human problems.
The Family Systems Perspective
Perhaps the most difficult adjustment for counselors and therapists from
Western cultures is the adoption of a “systems” perspective. Our personal experi-
ence and Western culture often tell us that we are autonomous individuals, capable
of free and independent choice. And yet we are born into families—and most of us
live our entire lives attached to one form of family or another. Within these families,
we discover who we are; we develop and change; and we give and receive the support
we need for survival. We create, maintain, and live by often unspoken rules and rou-
tines that we hope will keep the family (and each of its members) functional.
A family systems perspective holds that individuals are best understood through
assessing the interactions between and among family members. The development and
behavior of one family member is inextricably interconnected with others in the fam-
ily. Symptoms are often viewed as an expression of a set of habits and patterns within
a family. It is revolutionary to conclude that the identified client’s problem might
be a symptom of how the system functions, not just a symptom of the individual’s
maladjustment, history, and psychosocial development. This perspective is grounded
on the assumptions that a client’s problematic behavior may (1) serve a function or
purpose for the family; (2) be unintentionally maintained by family processes; (3) be
a function of the family’s inability to operate productively, especially during devel-
opmental transitions; or (4) be a symptom of dysfunctional patterns handed down
across generations. All these assumptions challenge the more traditional intrapsychic
frameworks for conceptualizing human problems and their formation.
The central principle agreed upon by family therapy practitioners, regardless of
their particular approach, is that the client is connected to living systems. Attempts
at change are best facilitated by working with and considering the family or set of
relationships as a whole. Therefore, a treatment approach that comprehensively
addresses the family as well as the “identified” client is required. Because a family is
an interactional unit, it has its own set of unique traits. It is not possible to accurately
assess an individual’s concern without observing the interaction of the other family
members, as well as the broader contexts in which the person and the family live.
Family therapy perspectives call for a conceptual shift from evaluating individu-
als to focusing on system dynamics, or how individuals within a system react to one
another. Actions by any individual family member will influence all family mem-
bers, and their reactions will have a reciprocal effect on the individual. When change
LO1
LO2
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F A m i l y S y S T E m S T H E R A P y 405
occurs, a ripple effect flows throughout the family system. Effective changes sup-
port the family system and the new behaviors of the individual or family (Lambert,
Carmichael, & Williams, 2016). Goldenberg and Goldenberg (2013) point to the
need for therapists to view all behavior, including all symptoms expressed by the
individual, within the context of the family and society. They add that a systems ori-
entation does not preclude dealing with the dynamics within the individual, but that
this approach broadens the traditional emphasis on individual internal dynamics.
Visit CengageBrain.com or watch the DVD for the video program on Chapter 14, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. i suggest that you view the
brief lecture for each chapter prior to reading the chapter.
Differences Between Systemic and Individual Approaches
There are significant differences between individual therapeutic approaches
and systemic approaches. A case may help to illustrate these differences. Ann, age 22,
sees a counselor because she is suffering from a depression that has lasted for more
than two years and has impaired her ability to maintain friendships and work pro-
ductively. She wants to feel better, but she is pessimistic about her chances. How will
a therapist choose to help her?
Both the individual therapist and the systemic therapist are interested in Ann’s
current living situation and life experiences. Both discover that she is still living at
home with her parents, who are in their 60s. They note that she has a very successful
older sister, who is a prominent lawyer in the small town in which the two live. The
therapists are impressed by Ann’s loss of friends who have married and left town
over the years while she stayed behind, often lonely and isolated. Finally, both thera-
pists note that Ann’s depression affects others as well as herself. It is here, however,
that the similarities tend to end:
The individual therapist may: The systemic therapist may:
Focus on obtaining an accurate diag-
nosis, perhaps using the DSM-5 (Amer-
ican Psychiatric Association, 2013)
Explore the system for family process
and rules, perhaps using a genogram
Begin therapy with Ann immediately Invite Ann’s mother, father, and sister
into therapy with her
Focus on the causes, purposes, and
cognitive, emotional, and behavioral
processes involved in Ann’s depression
and coping
Focus on the family relationships
within which the continuation of
Ann’s depression “makes sense”
Be concerned with Ann’s individual
experiences and perspectives
Be concerned with transgenerational
meanings, rules, cultural, and gender
perspectives within the system, and
even the community and larger sys-
tems affecting the family
Intervene in ways designed to help
Ann cope
Intervene in ways designed to help
change Ann’s context
LO3
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406 C H A P T E R F O U R T E E N
Systemic therapists do not deny the importance of the individual in the family
system, but they believe an individual’s systemic affiliations and interactions have
more power in the person’s life than a single therapist could ever hope to have. By
working with the whole family (or even community) system, the therapist has a
chance to observe how individuals act within the system and participate in main-
taining the status quo; how the system influences (and is influenced by) the indi-
vidual; and what interventions might lead to changes that help the couple, family,
or larger system as well as the individual expressing pain.
In Ann’s case, her depression may have organic, genetic, or hormonal compo-
nents. It may also involve cognitive, experiential, or behavioral patterns that inter-
fere with effective coping. Even if her depression can be explained in this manner,
however, the systemic therapist is very interested in how her depression affects oth-
ers in the family and how it influences family processes. Her depression may signal
both her own pain and the unexpressed pain of the family. Indeed, many family
system approaches would investigate how the depression serves other family mem-
bers; distracts from problems in the intimate relationships of others; or reflects her
need to adjust to family rules, to cultural injunctions, or to processes influenced by
gender or family life-cycle development. Rather than losing sight of the individual,
family therapists understand the person as specifically embedded in larger systems.
Development of Family Systems Therapy
Family systems theory has evolved throughout the past 100 years, and today
therapists creatively employ various perspectives when tailoring therapy to a par-
ticular family. Alfred Adler (1927) and Rudolf Dreikurs (1950, 1973) and their
associates were the first known practitioners of family therapy, often using a model
now called open-forum family counseling (Christensen, 2004). Adler introduced
phenomenology to our understanding of the family system (or family constella-
tion). Assessment is based on the subjective descriptions that family members use to
define themselves and the interactions that occur in everyday life. It is within these
interactions that Adlerians seek to discover the purposes and goals of behavior (Bit-
ter, 2014; Bitter, Roberts, & Sonstegard, 2002).
Take a moment and think about two different family experiences in your own
life. When you were little, what descriptions would you have used for your parents?
What do these descriptions tell you about what was important to you? Let’s say that
one’s father is described as kind, generous, and childlike. The mother is described
as beautiful, very hard working, and sacrificing. No adjective or description exists
outside of the relationship. When the person says the father was kind, this means
that the father was kind to the person as a child. When the mother is described as
very hard working, the person is suggesting that access to mother was difficult to get.
Still, mother’s hard work has a purpose: she is sacrificing for the child. What else can
we know from these descriptions? Father was generous and childlike: “he played with
me.” He may not have been very oriented toward discipline. Mother was beautiful.
The message is that for women appearances are important.
Now, think about your current family situation, either your family of origin
or a new family you have started. What descriptions would family members use to
LO4
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F A m i l y S y S T E m S T H E R A P y 407
describe you? What does that tell you about your place or role in the family? Finally,
think about a recent family interaction that was difficult for you. What goals or pur-
poses did you have for your part of the interaction? What goals or purposes might
have been involved for those interacting with you? You can generally discover the
goal or purpose of behavior by looking at the consequence of that behavior in the
responses of others: “What do people do when I act in one way or another?”
We now take a look at the most prominent models and what they have contrib-
uted to the evolution of family systems therapy.
MURRAY BOWEN (1913–1990) believed
families could best be understood when
analyzed from a three-generation per-
spective because patterns of interper-
sonal relationships connect family
members across generations. Two of
his objectives in therapy were to help
family members develop a rational,
nonreactive approach to living (called a
differentiation of self) and to de-tangle
family interactions that involved two
people pulling a third person into the
couple’s problems and arguments (or
triangulation).
Bowen’s observations led to his interest in pat-
terns across multiple generations. He contended
that problems manifested in one’s current family
will not significantly change until relationship pat-
terns in one’s family of origin are understood and
directly challenged. His approach operates on the
premise that a predictable pattern of interpersonal
relationships connects the functioning of family
members across generations. According to Kerr and
Bowen (1988), the cause of an individual’s prob-
lems can be understood only by viewing the role of
the family as an emotional unit. Within the family
unit, unresolved emotional reactivity to one’s family
must be addressed if one hopes to achieve a mature
and unique personality. Emotional problems will be
transmitted from generation to genera-
tion until unresolved emotional attach-
ments are dealt with effectively. Change
must occur with other family members
and cannot be done by an individual in a
counseling room.
Murray Bowen (1978) was one of the
original developers of mainstream family
therapy. His family systems theory, which
is a theoretical and clinical model that
evolved from psychoanalytic principles
and practices, is sometimes referred to as
multigenerational family therapy. The
goal of this approach is to differentiate self within a sys-
tem and to understand one’s family of origin. Bowen
and his associates implemented an innovative approach
to schizophrenia at the National Institute of Mental
Health where Bowen hospitalized entire families so
that the family system could be the focus of therapy.
Bowen’s emphasis on a multigenerational per-
spective laid a foundation for work by two of Bowen’s
most prominent colleagues, Betty Carter and Monica
McGoldrick, who almost single-handedly initiated
both a developmental and a multicultural perspec-
tive in family therapy. Indeed, McGoldrick’s work
includes the field’s most important work on geno-
grams (McGoldrick, Gerson, & Petry, 2008), family
life cycle (McGoldrick, Carter, & Garcia-Preto, 2011),
and gender (McGoldrick, Anderson, & Walsh, 1991).
Murray Bowen
Co
ur
te
sy
o
f T
he
B
ow
en
C
en
te
r f
or
th
e
St
ud
y
of
th
e
Fa
m
ily
;
ph
ot
o
by
A
nd
re
a
Sc
ha
ra
VIRGINIA SATIR (1916–1988) developed conjoint
family therapy, a human validation process model
that emphasizes communication and emotional expe-
riencing. Like Bowen, she used an intergenerational
model, but she worked to bring family patterns to life
in the present through sculpting and family recon-
structions. Claiming that techniques were secondary
to relationship, she concentrated on the personal
relationship between therapist and family to achieve
change. The core of Satir’s model relied on the power
of congruence to help family members communicate
with emotional honesty. Her presence with people
encouraged them to get in touch with what was sig-
nificant within, to become more fully human, and to
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408 C H A P T E R F O U R T E E N
Structural-Strategic Family Therapy
The origins of structural family therapy can be traced to the early 1960s when
Salvador Minuchin was conducting therapy, training, and research with delinquent
boys from poor families at the Wiltwyck School in New York. Minuchin’s (1974)
central idea was that an individual’s symptoms are best understood from the van-
tage point of interactional patterns, or sequences, within a family. He further stated
that structural changes must occur in a family before an individual’s symptoms can
be reduced or eliminated. The goals of structural family therapy include (1) reduc-
ing symptoms of dysfunction and (2) bringing about structural change within the
system by modifying the family’s transactional rules and establishing more appro-
priate boundaries.
In the late 1960s, Jay Haley joined Minuchin at the Philadelphia Child Guidance
Clinic. The work of Haley and Minuchin shared so many similarities in goals and
process that many clinicians in the 1980s and 1990s began to question whether the
two models were distinct schools of thought. Indeed, by the late 1970s, structural-
strategic approaches were the most used models in family systems therapy. The
interventions generated in these models became synonymous with a systems
approach; they included joining, boundary setting, unbalancing, reframing, ordeals,
paradoxical interventions, and enactments.
If you divided your family of origin into subsystems, who would be in the
parental subsystem? The spousal subsystem? The sibling subsystem? What
rules and boundaries were set around each subsystem? Were the boundaries
ever crossed? By whom and with what result? What were common interactional
sequences in your family? Who had the power in your family, and how was it
exercised? Who was aligned with whom, and what did they use that alignment
to achieve? These are just a few of the assessments structural-strategic therapists
taught us to consider.
share the individual’s best self with a
significant other. Satir called this experi-
ence “making contact,” and she believed
that it extended the peace one had
within to a peace between people and,
eventually, to a peace among people.
At about the same time that Bowen
was developing his approach, Virginia
Satir (1983) began emphasizing family
connection. Her therapeutic work had
already led her to believe in the value of
a strong, nurturing relationship based
on interest and fascination with those
in her care. Unlike Bowen, Satir could envision and
sought to support the development of a nurturing
triad: two people, for example parents,
working for the well-being of another,
perhaps a child. Satir thought of herself
as a detective who sought out and lis-
tened for the reflections of self-esteem
in the communication of her clients.
She placed a strong emphasis on the
importance of communication and meta-
communication in family interactions,
and the value of therapeutic validation
in the process of change (Satir & Bitter,
2000). From Satir, family therapy gets it
model for empathic listening, therapeutic
presence, and nurturance (Satir, Banmen, Gerber, &
Gomori, 1991).
Virginia Satir
Co
ur
te
sy
o
f T
he
V
irg
in
ia
S
at
ir
G
lo
ba
l N
et
w
or
k
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F A m i l y S y S T E m S T H E R A P y 409
Recent Innovations in Family Therapy
In the last decade, feminism, multiculturalism, and postmodern social constructionism
have all entered the family therapy field. These models are more collaborative,
treating clients—individuals, couples, or families—as experts in their own lives. The
therapeutic conversations start with the counselor in a “not-knowing” position in
which clients are approached with curiosity and interest. The therapist is socially
active and aids clients in taking a preferred stand in relation to the dominant cul-
ture that may be oppressing them. Therapy often incorporates “reflecting teams”
and “definitional ceremonies” to bring multiple perspectives to the work (see West,
Bubenzer, & Bitter, 1998).
Feminist, multicultural, and postmodern therapists are extremely aware of the
power they have entering into already established systems, and they work to pro-
mote understanding through curiosity and interest rather than through formal
assessments. Adopting a decentered position allows them to be part of the system
without taking it over.
Postmodern approaches to family therapy, like narrative therapy, seek to reduce
or eliminate the power and impact of the family therapist. Taken together, postmod-
ern approaches represent a real paradigm shift in the field of family therapy.
This brief discussion of the various systemic viewpoints in family therapy pro-
vides a context for understanding the development of family therapy. For an in-
depth treatment of the schools of family therapy, see Theory and Practice of Family
Therapy and Counseling (Bitter, 2014) and the recommended readings at the end of
the chapter.
A Multilayered Process of Family Therapy
Families are multilayered systems that both affect and are affected by the
larger systems in which they are embedded. Families can be described in terms of
their individual members and the various roles they play, the relationships between
the members, and the sequential patterns of the interactions and the purposes these
sequences serve. Both the members and the system can be assessed based on power,
alignment, organization, structure, development, culture, and gender (Breunlin,
Schwartz, & MacKune-Karrer, 1997). Even individuals can be considered from the
perspective of an internal family system (Schwartz, 1995). In addition, nuclear fami-
lies in a global community are often part of extended, if distant, families; multiple
families make up a community; multiple communities make up both regions and
cultures, which in turn constitute nations (or societies). The power of these macro-
systems to influence family life—especially in the areas of gender and culture—is sig-
nificant. Given our presuppositions about families and the larger systems in which
families are embedded, a multilayered approach to family therapy is essential.
Several forms and structures have been proposed for integrative models of fam-
ily counseling and therapy (e.g., Carlson, Sperry, & Lewis, 2005; Gladding, 2014;
Hanna, 2007; Nichols, 2013). The integrative model we have chosen to present here
allows for an enlarged integration of ideas from multiple models of family therapy.
Similar to a piece of classical music, the process of family therapy, it seems to us, has
LO5
LO6
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410 C H A P T E R F O U R T E E N
movements. These movements can be described as separate experiences embedded in
the larger flow of therapy. In this section we describe four general movements, each
with different tasks: forming a relationship, conducting an assessment, hypothesiz-
ing and sharing meaning, and facilitating change. In rare instances, these four move-
ments might occur within a single session; in most cases, however, each movement
requires multiple sessions.
Forming a Relationship
Over the years, family systems therapists have used a wide range of metaphors to
describe the role of the therapist and the therapeutic relationship. The emergence of
feminist and postmodern models in therapy has moved the field of family therapy
toward more egalitarian, collaborative, cooperative, co-constructing relationships
(see T. Andersen, 1987, 1991; H. Anderson, 1993; Anderson & Goolishian, 1992;
Epston & White, 1992; Luepnitz, 1988/2002).
The debate Carl Rogers (1980) first introduced to individual therapy in the
1940s has reemerged within family therapy in the form of these questions:
�� What expertise does the therapist have in relation to the family, and
how should that expertise be used?
�� How directive should therapists be in relation to families, and what
does that say about the uses of power in therapy?
We believe a multilayered approach to family therapy is best supported by a col-
laborative therapist–client relationship in which mutual respect, caring, empathy,
and a genuine interest in others is primary. In addition, we believe directed actions and
enactments are most useful when they are a joint venture of both the therapist and
the family.
Therapists begin to form a relationship with clients from the moment of
first contact. In most cases, we believe therapists should make their own appoint-
ments, answer initial questions clients may have, and give clients a sense of what
to expect when they come for their first session. This is also a time when coun-
selors can let families know their position on whether all members should be
present. Some family therapists will work with any of those members of the fam-
ily who wish to come; others will only see the family if everyone is a part of the
therapy session.
From the moment of first face-to-face contact, good therapeutic relation-
ships start with efforts at making contact with each person present (Satir & Bitter,
2000). Whether it is called joining, engagement, or simple care and concern, it is the
therapist’s responsibility to meet each person with openness and warmth. Gener-
ally, a focused interest on each family member helps to reduce the anxiety the
family may be feeling.
Therapeutic process and structure are part of the therapist’s job description.
It is important for family members to introduce themselves and to express their
concerns, but the therapist should not focus too tightly on content issues. Under-
standing family process is almost always facilitated by how questions. Questions
that begin with what, why, where, or when tend to overemphasize content details
(Gladding, 2014).
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F A m i l y S y S T E m S T H E R A P y 411
All change in human systems starts with understanding and accepting
things just as they are (Satir & Baldwin, 1983). The family practitioner’s skill
in communicating that understanding and empathy through active listening
lays the foundation for an effective working relationship. Those counselors and
therapists who use validation and encouragement, who support family resil-
ience, and who elicit cooperation experience the greatest amount of success in
therapy.
Conducting an Assessment
The multiple layers we have noted provide numerous entry points for conducting
family assessments, but beginning counselors and therapists will often find that
more formal assessment procedures, such as genograms (McGoldrick et al., 2008),
enable the family structure and stories to be presented in a clearer, more orderly
manner. In some cases, formal tests and rating scales also can be useful (see, for
example, Gottman, 1999).
Let’s start with the process for co-constructing a genogram. Most family practi-
tioners start with a map of the family that comes to therapy. The parents are listed
with their name, age, and date of birth in either a rectangle (for men) or a circle
(for women). If there are multiple relationships involved in the parental subsystem,
they are generally indicated in chronological order with men listed on the left and
women on the right.
Ralph
Age 30
1/17/81
John
Age 25
2/27/86
Mary
Age 24
12/22/87
m. 2006//d. 2008 m. 2010
In the above genogram, Mary married Ralph when she was 20 and Ralph was 26;
their marriage lasted about two years, and then they were divorced. In 2010, Mary
and John were married. If John and Mary had decided to live together, but not com-
mit to a formal marriage, the genogram would use a broken line (or dashes) to indi-
cate an informal relationship, like this:
John
Age 25
2/27/86
Mary
Age 24
12/22/87
If Ralph had died instead of divorcing Mary, it would look like this:
Ralph
Age 30
1/17/81
Mary
Age 24
12/22/87
d. 2008 m. 2006
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412 C H A P T E R F O U R T E E N
When Mary and John have children, their genogram may look like this:
John
Age 30
2/27/86
John, Jr.
Age 5
4/20/11
Mary
Age 29
12/22/87
Ann
Age 2
3/12/14
m. 2010
In the above genogram, it is now 2016, and John and Mary have been married
for six years. When they had been married for one year, Mary gave birth to their first
child, a boy that they named John Jr. A year later, Mary had a miscarriage, indicated
by a black oval at the end of a child line. Two years ago, they adopted (indicated by
a solid line next to a broken line) their daughter Ann. If we extend John and Mary’s
genogram to three generations and if we assume that both John and Mary were only
children, the basic three generation family genogram would look like this:
John
Age 30
2/27/86
John, Jr.
Age 5
4/20/11
Mary
Age 29
12/22/87
Ann
Age 2
3/12/14
m. 2010
His Parents Her Parents
Many other symbols are used in a genogram, including a double square or a
double circle to indicate the index person, or person on whom the genogram is
focused. An upside down triangle in a square or circle is used to indicate a gay man
or a lesbian woman. We shade the bottom half of a square or circle to indicate sub-
stance abuse. We use double parallel lines to indicate a strong relationship between
two people and three parallel lines to indicate a fused or enmeshed relationship. A
dotted line indicates a distant relationship, and conflict is indicated with lines that
look like this: /\/\/\/\/\/\/. Later in the chapter we use a genogram in our work with
Stan, but you now have enough information to construct your own genogram, and
we highly recommend that you get a large piece of paper and get started. It works
best if two people interview each other so that you are both drawing the genogram
and telling each other the story of your family.
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F A m i l y S y S T E m S T H E R A P y 413
As the therapist listens to family members describe the story of their family, it
may be difficult to know where to start with a family. Family members are often the
best people to choose a focus. Family practitioners may use circular or relational ques-
tioning to get at the systemic issues presented in the family story that will provide
meaning for the therapist and the family. For example, suppose Tammy is upsetting
the family system by ignoring the curfew her parents have set for her. The therapist
might ask: “What will happen if Tammy stays out past curfew and is picked up by the
police? Who will be most upset by this?” Here is Tammy’s father’s reply:
I will probably be the most upset on the outside. I tend to go off before I think,
and then I regret it later. On the other hand, her mother may not show it imme-
diately, but her hurt will stay with her longer, and then she will get mad at me for
“letting Tammy off the hook.” She will say that Tammy is manipulating me, but
I just don’t see why we should keep fighting about things. It doesn’t do any good.
We fight, and Tammy disappears. She wants to run with the big kids, some of
whom are in college, over 18, and have no curfew.
From this father’s response, the therapist can choose from a number of points
of entry into the life of this family. The counselor might choose to work with the
anger or guilt expressed by the members and present in their interactions. Sequen-
tial patterns were clearly articulated by the father when the family members are try-
ing to resolve conflict and handle problems. His description also includes implied
positions on the roles of men, women, and female children in families—as well as
developmental issues related to Tammy wanting to be older than she is.
In the assessment process, it is helpful to inquire about family perspectives on
issues inherent in each of these layers. In addition to the points of entry we have
noted, here are some other questions that might be included in a more detailed
assessment.
�� What does each family member bring to the session?
�� How does each person describe who he or she is?
�� What are the goals of each family member? What goals does each fam-
ily member have for the other people in the family?
�� What routines support the daily living of each member of the family?
�� Who makes decisions? How are conflicts resolved or problems handled?
�� What parts are involved in the most common sequences in the family?
�� What is a typical day like?
�� Are the parents effective leaders of the family, and is the process of lead-
ership balanced or imbalanced?
�� How do the children respond to parental leadership? What are the chil-
dren’s goals in responding the way they do?
�� Where is each person in the family in relation to personal biological,
cognitive, emotional, and social development?
�� Where is the family in the family life cycle, and how are they handling
transitions?
�� What cultures are in the family backgrounds of each of the family
members?
�� In what culture or region is the family currently living, and is immigra-
tion or migration a recent family experience?
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414 C H A P T E R F O U R T E E N
�� How do economics, education, ethnicity, religion, race, regional back-
ground, gender, sexual orientation, ableness, and age affect family
processes—and how is the fit between the family practitioner and the
family with regard to these aspects of family life?
�� What effects has racism, patriarchy, or heterosexism had on this family
and its members?
�� What ideas in relation to gender need to be affirmed or challenged?
�� Where is this family in the process of change?
�� What resources (internal or external) need to be accessed?
Hypothesizing and Sharing Meaning
To hypothesize is to form a set of ideas about people, systems, and situations that
focus meaning in a useful way. In family therapy, hypothesizing flows from the ideas
and understandings generated in the assessment process. Two questions are ger-
mane to the form of hypothesizing one chooses to do: (1) How much faith do the
therapist and the family have in the ideas they generate? (2) How much of an influ-
ence is the therapist willing to be in the lives of people and families?
Family counselors, like individual therapists, cannot avoid influencing the
family and its members. But what kind of influence will the therapist bring to the
session? Satir and Bitter (2000) suggest that family therapists cannot be in charge
of the people, but they need to be in charge of the process; that is, they own the
responsibility for how therapy is conducted. Feminists and social constructionists
are, perhaps, the most expressive of their concerns about the misuse of power in
therapy. They are joined by multiculturalists, person-centered therapists, Adlerians,
and existentialists, to name a few, who have also witnessed the often unconscious
imposition of “dominant culture” in therapy. In the early days of family therapy,
the mostly male therapists often ignored the effects on family life of patriarchy,
poverty, racism, cultural discrimination and marginalization, homo-prejudice, and
other societal problems. At the strategic-structural end of the continuum, thera-
pists were more likely to claim a certain expertise in systems work that allowed
them to make direct interventions in the enactment of “needed” changes in the
family. To counteract therapeutic abuses and what some perceived to be an ongo-
ing misuse of power in therapy, some narrative therapists adopted a decentered posi-
tion in relation to the family (White, 1997, 2007). Like person-centered therapists
before them, decentered therapists seek to keep families and family members at the
center of the therapeutic process.
It is important for families to be invited into respectful, essentially collaborative
dialogues in therapeutic work. The different perspectives discovered in this work
tend to coalesce into working hypotheses, and sharing these ideas provides the fam-
ily with a window into the heart and mind of the therapist as well as themselves.
Sharing hypotheses almost immediately invites and invokes feedback from various
family members. And it is this feedback that enables the therapist and the family
to develop a good fit with each other, which in turn tends to cement a working
relationship.
The tentative hypothesizing and sharing process that Dreikurs (1950, 1997)
developed is well designed for the kind of collaborative work envisioned here.
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F A m i l y S y S T E m S T H E R A P y 415
Dreikurs would use a passionate interest and curiosity to ask questions and gather
together the subjective perspectives of family members. Indeed, he would honor the
ideas that individuals brought to their joint understanding. When he had an idea
that he wanted to share, he would often seek permission for his disclosure:
1. I have an idea I would like to share with you. Would you be willing to
hear it?
2. Could it be that . . .
The value of this way of presenting hypotheses is that it invites families and family
members to consider and to engage without giving up their right to discard any-
thing that does not fit. When a suggested idea does not fit, the therapist is then clear
about letting it go and letting the family redirect the conversation toward more use-
ful conceptualizations.
Facilitating Change
Facilitating change is what happens when family therapy is viewed as a joint or col-
laborative process. Techniques are more important to models that see the therapist-
as-expert and in charge of making change happen. Collaborative approaches require
planning. “Planning can still include what family therapy has called techniques or
interventions, but with the family’s participation” (Breunlin et al., 1997, p. 292). Two
of the most common forms for facilitation of change are enactments and assign-
ment of tasks. Both of these processes work best when the family co-constructs
them with the therapist—or at least accepts the rationale for their use.
Within the change process, the number of possible outcomes is only limited by
the resources available internally and externally to the family. This does not mean,
however, that the family practitioner is without a guide for preferred or desired out-
comes. In general, the internal parts of family members function best when they
are balanced (not polarized) and when the individual experiences personal parts
as resources. Being able to think is usually more useful than emotional reactivity;
being able to feel is better than not feeling; good contact with others is more reward-
ing than isolation or self-absorption; and taking reasonable risks in the service of
growth and development is more beneficial than stagnation or a retreat into fear.
Further, knowing the goals and purposes for our behaviors, feelings, and inter-
actions tends to give us choices about their use. And understanding the patterns
we enact in face-to-face relationships, the ebbs and flows of life, or across genera-
tions provide multiple avenues for challenging patterns and the enactment of new
possibilities.
Family Systems Therapy From a Multicultural Perspective
Strengths From a Diversity Perspective
One of the strengths of the systemic perspective in working from a multi-
cultural framework is that many ethnic and cultural groups place great value on
the extended family. If therapists are working with an individual from a cultural
background that gives special value to including grandparents, aunts, and uncles
LO7
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416 C H A P T E R F O U R T E E N
in the treatment, it is easy to see that family approaches have a distinct advantage
over individual therapy. Family therapists can do some excellent networking with
members of the extended family.
Within the field of family therapy, Monica McGoldrick has been the most influ-
ential leader in the development of both gender and cultural perspectives and frame-
works in family practice (see McGoldrick et al., 1991, 2005; McGoldrick, & Hardy,
2008). In many ways, McGoldrick and her colleagues approach families like systems
anthropologists. They see each family as a unique culture whose particular charac-
teristics must be understood. Like larger cultural systems, families have a unique
language that governs behavior, communication, and even how to feel about and
experience life. Families have celebrations and rituals that mark transitions, protect
them against outside interference, and connect them to their past as well as to a
projected future.
Similarly, families cannot escape the sexism and patriarchy that are inherent
in all cultures. The roles for men and women are prescribed in different societies,
but in every culture women tend to come out on the short end more often than
not. The roles that women as mothers play in the family, in the world of work, and
in the community set the model for female children often for generations to come.
Because family life is where the roles of women can be most limited, a consideration
of gender issues in families is an essential framework for family therapy (McGold-
rick et al., 1991). Perhaps the most difficult integration of all is figuring out how to
honor different cultures in therapy without supporting marginalization or oppres-
sion of women. Toward this end, it is important to remember that there are feminist
voices in every culture throughout the world.
Just as differentiation means coming to understand our family well enough to
be a part of it—to belong—and also to separate and be our own person, understand-
ing cultures allows therapists and families to appreciate diversity and to contextu-
alize family experiences in relation to the larger cultures. Today, family therapists
explore the individual culture of the family, the larger cultures to which the family
members belong, and the host culture that dominates the family’s life. They look
for ways in which culture can both inform and modify family work. Interventions
are no longer applied universally, regardless of the cultures involved: rather, they are
adapted and even designed to join with the cultural systems.
Shortcomings From a Diversity Perspective
Given the multicultural focus and collaborative approach of family systems ther-
apy, it is difficult to find shortcomings from a diversity perspective. This model
of family therapy embraces attitudes, knowledge, and skills that are essential to
a multicultural perspective. Perhaps the major concern for non-Western cultures
would be with regard to the balance that this model advocates for the individual
versus the collective. The process of differentiation occurs in most cultures, but
it takes on a different shape due to cultural norms. For instance, a young person
may become separate from her parents yet not move out of the house. When eth-
nic-minority families immigrate to North America, their children often adapt to a
Western concept of differentiation. In such cases, the intergenerational process of
therapy is appropriate if the therapist is sensitive to the family-of-origin’s cultural
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F A m i l y S y S T E m S T H E R A P y 417
roots. Although a multilayered approach addresses the notion of togetherness and
individuality from a balanced perspective, many non-Western cultures would not
embrace a theory that valued individuality above loyalty to family in any form. Nor
would non-Western cultures have the same conceptualizations of time or even emo-
tions. Therapists, regardless of their model of therapy, must find ways to enter the
family’s world and honor the traditions that support the family.
A possible shortcoming of the practice of family therapy involves practitioners
who assume Western models of family are universal. Indeed, there are many cultural
variations to family structure, processes, and communication. Family therapists are
finding ways to broaden their views of individuation, appropriate gender roles, fam-
ily life cycles, and extended families. Some family therapists focus primarily on the
nuclear family, which is based on Western notions, and this could clearly be a short-
coming in working with clients in extended families.
In our work with Stan in this modality, we include examples of forming a relationship and joining,
reading Stan’s genogram, a multilayered assessment,
reframing, boundary setting in therapy, and facilitat-
ing change. There are many useful models and ways
to work with families; this discussion represents some
possible ways to work with Stan from a multilayered
perspective.
At an intake interview, a family therapist meets
with Stan to explore his issues and concerns and to
learn more about him and his life situation. As they
talk, the therapist brings an intense interest and curios-
ity to the interview and wonders out loud about the fa-
milial roots of some of Stan’s problems. It does not take
much of an inquiry to learn that Stan is still very much
engaged with his parents and siblings, no matter how
difficult these relationships have been for him. This
initial conversation involves the development of a geno-
gram of Stan’s family of origin (see Figure 14.1). This
map will serve both Stan and the therapist as a guide to
the people and the processes that influence Stan’s life.
Stan’s genogram is really a family picture, or map,
of his family-of-origin system. In this genogram, we
learn that Stan’s grandparents tend to have lived fairly
long lives. Stan’s maternal grandparents are both alive.
The shaded lower half of their square and circle indi-
cates that each had some problem with alcohol. In the
case of Tom, Stan reports that he was an admitted al-
coholic who recommitted himself to Christ and found
help through Alcoholics Anonymous. Stan’s maternal
grandmother always drank a little socially and with
her husband, but she never considered herself to have
a problem. In her later years, however, she seems to se-
cretly use alcohol more and more, and it is a source of
distress in her marriage. Stan also knows that Margie
drinks a lot, because he has been drinking with his aunt
for years. She is the one who gave him his first drink.
Angie, Stan’s mother, married Frank Sr. after he
had stopped drinking, also with the help of AA. He
still goes to meetings. Angie is suspicious of all men
around alcohol. She is especially upset with Stan
and with Judy’s husband, Matt, who “also drinks too
much.” The genogram makes it easy to see the pattern
of alcohol problems in this family.
The jagged lines /\/\/\/\ between Frank Sr. and
Angie indicate conflict in the relationship. The three
solid lines === between Frank Sr. and Frank Jr., and
between Angie and Karl, indicate a very close or even
fused relationship. The double lines ==== between
Karl and Stan are used to note a close relationship
only. As we will see, Karl actually looks up to Stan in
this family. The dotted lines . . . . . between Frank Sr.
and Stan and between Frank Jr. and Stan indicate a
distant or even disengaged relationship.
Because the family therapist believes that the whole
family is involved in Stan’s use of alcohol, she spends a
good part of the first session exploring with Stan pro-
cesses for asking his other family members to join him
in therapy. Stan may have many difficulties, but at the
moment his difficulty with alcohol is the primary focus.
Family Therapy Applied to the Case of Stan
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418 C H A P T E R F O U R T E E N
Alcohol is a negative part of his life, and as such it has
systemic meaning. It may have started out as a symptom
of other problems, but now the alcohol is a problem
in itself. From a systemic perspective, the questions are
“How does this problem affect the family?” and “Is the
family using this problem to serve some other purpose?”
In the first therapy session with the family, the
therapist’s main focus is in forming a relationship
with each of the family members, but even here, a vari-
ety of approaches present themselves.
Therapist [to Frank Sr.]: I know coming here was an
inconvenience for you, but I want you to know how
appreciative I am that you came. Can you tell me
what it’s like for you to be here? [Forming a relation-
ship through joining]
Frank Sr.: Well, I have to tell you that I don’t like it
much. [Pause] Things are a lot different today than
they used to be. We didn’t have counseling 20 years
ago. I had a problem with drinking at one point,
but I got over it. I just quit—on my own. That’s
what Stan needs to do. He just needs to stop.
Therapist: So I’m hearing that life is better for you
without alcohol, and you would like Stan’s life to
be better too. [Reframing]
Frank Sr.: Yeah. I’d like his life to be better in a lot of
different ways.
Judy
b. 1963
Mary
b. 1963
Joseph
b. 1907
Oris
b. 1938
Matthew
Stan
b. 1988
Frank Sr.
b. 1940
Matt
b. 1960 Frank Jr.
b. 1966
Stan
b. 1970
Karl
b. 1972
Seth
b. 1942
Emma
b. 1917
m. 1937
d. 1977
(Cancer)
d. 1968
(Vietnam)
Martha
b. 1921
Margie
b. 1944
Angie
b. 1942
m. 1940
m. 1962
Tom
b. 1920
= Problem with alcohol
Figure 14.1 Three Generation Genogram of Stan’s Family
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F A m i l y S y S T E m S T H E R A P y 419
Therapist: Angie, what about you? What is it like
for you to be here? [Forming a relationship with each
member]
Angie: It’s heartbreaking. It’s always heartbreaking.
He [Referring to Frank Sr.] makes it sound as if he
just summoned up his own personal power and
quit drinking through his own strength of charac-
ter. That’s a laugh. I threatened to leave him. That’s
what really happened. I was ready to get a divorce!
And we’re Catholics. We don’t get divorced. [Possible
face-to-face sequence around family stress and coping]
Therapist: So you’ve been through this before.
Angie: Oh my, yes. My father and mother drank. Dad
still does. My sister won’t admit it, but she drinks
too much. She goes crazy with it. Judy’s husband
has a problem. I’m surrounded by alcoholics. I get
so angry. I wish they would all just die or go away.
[Possible transgenerational family sequence: an entry
point for exploring values, beliefs, and rules]
Therapist: So this is something the whole family has
been dealing with for a long time.
Angie: Not everyone. I don’t drink. Frankie and
Judy don’t drink. And Karl doesn’t seem to have
a problem.
Therapist: Is that how the family gets divided: into
those who drink and those who don’t? [Possible
organization perspective]
Judy: Drinking isn’t the only problem we have. It’s
probably not even the most important.
Therapist: Say more about that.
Judy: Stan has always had it hard. I feel sorry for him.
Frankie is clearly Dad’s favorite [Frank Sr. protests,
saying he doesn’t have favorites], and things have al-
ways come easily for me. And Karl, he gets whatever
he wants. He’s Mom’s favorite. Mom and Dad have
fought a lot over the years. None of us have been
that happy, but Stan seems to have the worst of it.
[Again, possible sequence and organization perspectives]
Frank Jr.: As I remember it, Stan gave Dad and Mom a
lot to fight about. He was always messing up in one
way or another.
Therapist: Frankie, when your father was talking
earlier, I sensed he had some disappointment about
Stan too, but he also wanted to see things work out
better for him. Is that true for you too? [Reframing
Frankie’s comment, maintaining a focus on new possibili-
ties and new relations that might be developed]
Frank Jr.: Yes. I would like his life to be better.
The initial part of this counseling session has been
devoted to meeting family members, listening intently
to the multiple perspectives they present, and refram-
ing Stan’s problem into a family desire for a positive
outcome. Although there is a long way to go, the seeds
of change have already been planted. There is evidence
in these early interactions that Stan’s problem has a
multigenerational context. If this context is explored,
family sequences that support and maintain alcohol
as a problem may be identified. It is possible to track
these interactions and to work toward more congru-
ent communications. Evolving relational, organiza-
tional, developmental sequences might be explored
as a means of freeing family members for new possi-
bilities in their life together. Among other possibilities
still to be explored are perspectives related to gender
and culture. If the therapist were just listening to Stan,
only one point of view would be evident. In this family
session, multiple perspectives and the entire interac-
tive process become clear in a very short time.
As the family interview proceeds, a number of pos-
sibilities are presented for consideration. The therapist
considers and may structure therapy around any or all
of the following possibilities:
1. Stan’s parents have not been a well-functioning
leadership team for a long time, and both their
spousal relationship and their parenting have
suffered.
2. The adult siblings need a new opportunity to func-
tion together without the influence and distrac-
tions continually imposed by the parents.
3. Stan has been reduced to a single part (his alco-
holic part), and his description and experience of
himself needs to be enlarged—both for his own
perspective and in the eyes of others.
A new place for Stan in the family, a better way
of relating, and an ability to access “lost” parts of his
internal system are all critical to winning his battle
with alcohol. As therapy continues, it becomes clear
that two separate relational–organization hypotheses
must be explored. One is that the spousal relation-
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420 C H A P T E R F O U R T E E N
ship has been defined by the problem of alcohol too,
and it has not evolved or developed in any kind of
positive way over the years. Second, the transgen-
erational sequences have targeted Stan and assigned
him to a fixed role that he has been expected to play
that has blocked development past his middle to late
adolescence, which was the period in which he start-
ed drinking.
Questions for Reflection
�� What unique values do you see in working
with Stan from a multilayered, systemic per-
spective as opposed to an individual therapy
approach?
�� What internal parts might Stan re-access as he
continues in therapy? What parts of him might be
polarized?
�� Assuming that Stan was successful in getting
at least some of his family members to another
session, where would you begin? Would you get
everyone involved in the sessions? If so, how would
you do that?
�� What are some specific ways to explore other per-
spectives with this family?
�� What hypotheses are you developing, and how
would you share them with the family?
�� Are there systemic interventions that you would
find hopeful in terms of facilitating change?
As a family therapist, I look at Gwen as the index person in the context of her family system. Gwen
has a strong extended family system and kinship ties
that go beyond blood relatives to close friends who
are called aunts, uncles, and cousins. When Gwen
begins to experience episodes of depression and feels
overwhelmed, the entire family is affected. African
American families often become enmeshed due to our
collectivistic nature. The cultural theme most often ex-
pressed is that “when something happens to one of us,
it happens to all of us.” It has been challenging to get
Gwen’s entire family in for a session, but she has man-
aged it. The extended family is a great strength in the Af-
rican American community, and Gwen’s family has pro-
vided her with a great deal of love and support. I want to
validate these efforts and let the family know that they
are already doing many things to support Gwen.
I invite everyone in, greeting each one individu-
ally. My first step with the family is to join with them
by finding out how they feel about being in session.
Ron: [Gwen’s husband] I rushed from work to be here,
because, well, I want Gwen to feel better. I have
to say I was not so sure about this when she first
brought it up. I am not used to talking to strangers
about my business, but I trust Gwen. I want what is
best for her.
Therapist: Thanks Ron, I appreciate you being here.
I know that you all have busy lives. But what is it
that you want for yourself from these sessions?
Ron: Well, Gwen, she is an amazing woman, but …
when she has these episodes of depression, I feel
helpless and nervous. I want to figure this thing
out and get past it. I want my wife to feel better,
and I want to help her however I can.
Therapist: I get the feeling that you would move
heaven and earth to help your wife be happier than
she is right now.
Ron: Yes, I certainly would.
Therapist: I appreciate that. And Lisa, what about
you?
Lisa: [the youngest daughter, age 26] I want Mom to feel
better, she is such a powerhouse. She helps every-
one else, and then she crashes. I am a little nervous
to be here. I don’t want to find out that she is going
through this because of something I did. She helps
me out with my bills, and I know I could do more
for her. I never help her with grandma, and I know
that is just more work for her.
Therapist: Lisa, I am sure that is important for your
mother to hear. But before I ask her to respond, I
would like to hear from other family members.
Family Therapy Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from a family therapy perspective and applying this model to Gwen.
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F A m i l y S y S T E m S T H E R A P y 421
Brittany: [the eldest daughter, age 29] I have been really
busy trying to get my career established. Mom has
been helping me, and I really had no idea she was
feeling overwhelmed and depressed. I am not sure
I really understand what is happening. I love my
mom, and I want to be here for her. She has always
had these ups and downs. Is this any different? I
love my mom, but she is so busy that I have given
up on trying to keep up with her. So when I hear
she wants to have a session, I am confused. Dad is
so good with her. He keeps everything rolling when
she is feeling down.
Therapist: I hear both your confusion and your
willingness to be here for your mom. Gwen, what is
this like for you?
Gwen: I am so thankful that I have such a loving
family that is willing to come talk to a complete
stranger so that I can get the help I need. Right
now I am feeling overwhelmed with life, and I am
tired of it. I am juggling so many things and feel
like nothing is getting done. I know this has been
going on for long time, but I am ready to find a bet-
ter way of living. I know this pattern has not been
easy for any of you, and I feel guilty over that too. I
don’t want to hide in bed anymore, like I remember
my mom doing. I am not getting any younger, and
I am so ready to show up in life in a healthier way.
Therapist: What would that look like?
Gwen: Well, I don’t know for sure. I would be happy,
I guess. I would not be worried about work or the
family so much.
Therapist: And what would your family be doing if
you were happier and healthier?
Gwen: I guess they would be happier too. It seems like
if I am happy, then they are too.
Therapist: But how can you be happy and healthy
with all these burdens hanging on you?
Gwen: I am hoping you can tell me.
Therapist: Would it be OK with you if I gave that
a try?
Gwen: Yes, please.
Therapist: Here is what I think is almost always true.
A super responsible person is always surrounded
by people who will let her take charge and handle
everything.
Gwen: What do you mean by that?
Therapist: It means, Gwen, that you have been in
charge for a very long time, and you have forgotten
how to ask for help. Maybe you never knew how to
do that. But as long as you keep pushing forward,
your family will let you.
Gwen’s Mother: That’s right there!
Ron: Wait a minute. I do everything I can to keep
things moving! What else do you need?
Gwen: I don’t know. I am just hearing that I need
help.
Therapist: So that’s the issue for this family. Mom
is the only one that knows everything that needs
to happen. She knows how to do everything, but
she is overloaded. She doesn’t know how to ask
for help, and everyone else is hoping she won’t
because everyone is busy and overloaded. And,
Gwen, even if you did ask for help from others,
would you worry whether they were doing it
right?
Brittany: Are you kidding? She would be supervising
everything anyway.
Therapist: And how many of you would know how
to mess it up just enough so that mom would take
over again? [pause while family members look at each
other; some smile a bit; some hang their heads] Wow.
That brought everything to a standstill. Where do
we go from here?
Ron: Maybe we need to go home and think about
this. We definitely need to do something differ-
ently. I want to talk to your brother and let him
know how much pressure your mom is under so
he can start taking care of his own business. We
better start by making a list of everything Gwen
has been doing and see where we need to step up.
[pause] And maybe Gwen needs to stay out of
this part.
Therapist: Let’s see where that goes.
We set a time for future sessions, and I let them
know that coming in for therapy shows their com-
mitment to Gwen and to each other as a family unit. I
want them to know that I understand what it took for
them to make it in the door and that their efforts are
commendable.
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Summary and Evaluation
Summary
Let’s first review the themes that unite the many approaches to family ther-
apy, with particular emphasis on the multilayered approach.
Basic Assumption If we hope to work therapeutically with an individual, it is
critical to consider him or her within the family system. An individual’s problematic
behavior grows out of the interactional unit of the family as well as the larger
community and societal systems.
Focus of Family Therapy Most of the family therapies tend to be brief because
families who seek professional help typically want resolution of some problematic
symptom. Changing the system can stimulate change quickly. In addition to being
short-term, solution-focused, and action-oriented, family therapy tends to deal
with present interactions. The main focus of family therapy is on here-and-now
interactions in the family system. One way in which family therapy differs from
many individual therapies is its emphasis on how current family relationships
contribute to the development and maintenance of symptoms.
Role of Goals and Values Specific goals are determined by the practitioner’s
orientation or by a collaborative process between family and therapist. Global goals
include using interventions that enable individuals and the family to change in
ways that will reduce their distress. Tied to the question of what goals should guide
a therapist’s interventions is the question of the therapist’s values. Family therapy
is grounded on a set of values and theoretical assumptions. Ultimately, every
intervention a therapist makes is an expression of a value judgment. It is critical for
therapists, regardless of their theoretical orientation, to be aware of their values and
monitor how these values influence their practice with families.
How Families Change An integrative approach to the practice of family therapy
includes guiding principles that help the therapist organize goals, interactions,
observations, and ways to promote change. Some perspectives of family systems
therapy focus on perceptual and cognitive change, others deal mainly with
changing feelings, and still other theories emphasize behavioral change. Regardless
422 C H A P T E R F O U R T E E N
Questions for Reflection
�� What did you think of the way the therapist inter-
vened to get family members connected in their
first family therapy session?
�� What do you imagine it would be like for you to
be a participant in this family therapy session with
this therapist?
�� What value do you see for Gwen in having a fam-
ily therapy session in addition to her individual
therapy sessions?
�� Beginning therapists are usually anxious about hav-
ing so many people in the room because it can be
confusing. How did the therapist in this case man-
age the session so that it did not become chaotic?
LO8
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F A m i l y S y S T E m S T H E R A P y 423
of the perspectives that a family therapist operates from, change needs to happen in
relationships, not just within the individual.
Techniques of Family Therapy The intervention strategies therapists employ are
best considered in conjunction with their personal characteristics. Bitter (2014),
Goldenberg and Goldenberg (2013), and Nichols (2013) emphasize that techniques
are tools for achieving therapeutic goals but that these intervention strategies do
not make a family therapist. Personal characteristics such as respect for clients,
compassion, empathy, and sensitivity are human qualities that influence the
manner in which techniques are delivered. It is also essential to have a rationale
for the techniques that are used, with some sense of the expected outcomes. Faced
with meeting the demands of clinical practice, practitioners will need to be flexible
in selecting intervention strategies. The central consideration is what is in the best
interests of the family.
A multilayered approach to family therapy is more complex than models with
a singular focus. At least initially, some of the confidence and clarity that might
be gained from a single approach may be lost, but in time the flexibility to change
directions is an asset. We have presented a structure for therapy that is useful across
models. We have integrated a multilayered process of family therapy in assessment,
hypothesizing, and facilitating change. This chapter has described a collabora-
tive process for therapy in which both the family and the therapist share influence
according to the needs of the situation.
Contributions of Family Systems Approaches
One of the key contributions of most systemic approaches is that neither the indi-
vidual nor the family is blamed for a particular dysfunction. The family is empow-
ered through the process of identifying and exploring internal, developmental,
and purposeful interactional patterns. At the same time, a systems perspective rec-
ognizes that individuals and families are affected by external forces and systems,
among them illness, shifting gender patterns, culture, and socioeconomic consider-
ations. If change is to occur in families or with individuals, therapists must be aware
of as many systems of influence as possible.
Most of the individual therapies considered in this textbook fail to give a pri-
mary focus to the systemic factors influencing the individual. Family therapy rede-
fines the individual as a system embedded within many other systems, which brings
an entirely different perspective to assessment and treatment. An advantage to this
viewpoint is that an individual is not scapegoated as the “bad person” in the family.
Rather than blaming either the “identified patient” or a family, the entire family has
an opportunity (a) to examine the multiple perspectives and interactional patterns
that characterize the unit and (b) to participate in finding solutions.
Limitations and Criticisms of Family Systems Approaches
In the early days of family therapy, therapists all too often got lost in their consid-
eration of the “system.” In adopting the language of systems, therapists began to
describe and think of families as being made up of “dyads” and “triads”; as being “func-
tional” or “dysfunctional,” “stuck” or “unstuck,” and “enmeshed” or “disengaged”;
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424 C H A P T E R F O U R T E E N
and as displaying “positive” and “negative” outcomes and “feedback loops.” It was
as if the family was a well-oiled machine or perhaps a computer that occasionally
broke down. Just as it was easy to fix a machine without an emotional consideration
of the parts involved, some therapists approached family systems work with little
concern for the individuals as long as the “whole” of the family “functioned” better.
Enactments, ordeals, and paradoxical interventions were often “done to” clients—
sometimes even without their knowledge (see Haley, 1963, 1976, 1984; Minuchin &
Fishman, 1981; Selvini Palazzolli, Boscolo, Cecchin, & Prata, 1978).
Feminists were perhaps the first, but not the only, group to lament the loss of
a personal perspective within a systemic framework. As the field moves now toward
an integration of individual and systemic frameworks, it is important to reinvest the
language of therapy with human emotional terminology that honors the place real
people have always held in families. It is our hope that this chapter gives you enough
of an introduction to the diverse field of family therapy that you will want to learn
more through reading as well as watching the many video currently available.
Self-Reflection and Discussion Questions
1. Several different approaches to family therapy are described in this
chapter. Which of these approaches most interests you, and why?
2. How do you imagine it would be for you to be with your family as
a participant in family therapy? What do you think you could learn
about yourself from this experience?
3. What do you think you will need to learn and to experience before you
will be able to effectively work with a family?
4. How do the family systems therapy approaches differ from other theo-
ries that you have studied thus far?
5. What are some major advantages of working with a family therapy per-
spective? Can you think of any disadvantages?
Where to Go From Here
You may want to consider joining the American Association for Marriage and Fam-
ily Therapy, which has a student membership category. You must obtain an official
application, including the names of at least two Clinical Members from whom the
association can request official endorsements. You also need a statement signed by
the coordinator or director of a graduate program in marital and family therapy in
a regionally accredited educational institution, verifying your current enrollment.
Student membership may be held until receipt of a qualifying graduate degree
or for a maximum of five years. Members receive the Journal of Marital and Family
Therapy, which is published four times a year, and a subscription to six issues yearly
of The Family Therapy Magazine. For a copy of the AAMFT Code of Ethics, member-
ship applications, and further information, contact:
American Association for Marriage and Family Therapy
www.aamft.org
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F A m i l y S y S T E m S T H E R A P y 425
The American Counseling Association has a division devoted to couples and
family therapy called the International Association of Marriage and Family Coun-
seling (IAMFC). This division publishes The Family Journal and The Family Digest and
provides access to couples and family training and programs at the ACA convention.
For more information, contact:
International Association of Marriage and Family Counseling
www.iamfconline.org/public/main.cfm
Recommended Supplementary Readings
Theory and Practice of Family Therapy and Counseling
(Bitter, 2014) is a comprehensive textbook that
seeks to develop personal and professional growth
in family practitioners as well as orient the reader to
the theories that make up the field of family therapy
and counseling.
Family Therapy: History, Theory, and Practice (Gladding,
2014) is an overview of family therapy models and
therapeutic interventions designed for counselors
associated with ACA.
Family Therapy: An Overview (Goldenberg & Golden-
berg, 2013) provides an excellent basic overview of
these contemporary perspectives on family therapy.
Ethnicity and Family Therapy (McGoldrick, Giordano,
& Garcia-Preto, 2005) is the seminal work on cul-
ture in family therapy. The authors review the
importance of cultural considerations in relation
to family therapy and provide chapters on the back-
ground, research, and therapy issues of more than
15 cultures.
Family Therapy: Concepts and Methods (Nichols, 2013)
is an AAMFT-based text that covers seven of the
major contemporary family systems models. The
final chapter presents an integration of key themes
among diverse approaches to family therapy.
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427
15An Integrative Perspective
1. Explain psychotherapy integration
and why it is increasing in
popularity.
2. Identify some specific advantages
of psychotherapy integration.
3. Examine some of the main
challenges of developing an
integrative approach.
4. Discuss how multicultural issues
can be addressed in counseling
practice.
5. Discuss how spiritual and religious
values can ethically and effectively
be integrated into counseling
practice.
6. Understand a basis for effectively
drawing techniques from various
theories.
7. Examine what research generally
shows about the effectiveness of
psychotherapy.
8. Describe feedback-informed
treatment and explain how this is
related to enhanced therapeutic
outcomes.
L e a r n i n g O b j e c t i v e s
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428 C H A P T E R F I F T E E N
Introduction
This chapter will help you think about areas of convergence and divergence among
the 11 therapeutic systems covered in this book. Although these approaches all have
some goals in common, they have many differences when it comes to the best route
to achieve these goals. Some therapies call for an active and directive stance on the
therapist’s part, and others place value on clients being the active agent. Some ther-
apies focus on experiencing feelings, others stress identifying cognitive patterns, and
still others concentrate on actual behavior. The key task is to find ways to integrate
certain features of each of these approaches so that you can work with clients on all
three levels of human experience.
The field of psychotherapy is characterized by a diverse range of specialized
models. With all this diversity, is there any hope that a practitioner can develop
skills in all of the existing techniques? How does a student decide which theories
are most relevant to practice? Looking for commonalities among the systems of
psychotherapy is relatively new (Norcross & Beutler, 2014). Practitioners have been
battling over the “best” way to bring about personality change dating back to the
work of Freud. For decades, counselors resisted integration, often to the point of
denying the validity of alternative theories and of ignoring effective methods from
other theoretical schools. The early history of counseling is full of theoretical wars.
Since the early 1980s, psychotherapy integration has developed into a clearly
delineated field. It is now an established and respected movement that is based on
combining the best of differing orientations so that more complete theoretical mod-
els can be articulated and more efficient treatments developed (Goldfried, Pachan-
kis, & Bell, 2005). The Society for the Exploration of Psychotherapy Integration,
formed in 1983, is an international organization whose members are professionals
working toward the development of therapeutic approaches that transcend single
theoretical orientations. As the field of psychotherapy has matured, the concept of
integration has emerged as a mainstay (Norcross & Beutler, 2014).
In this chapter I consider the advantages of developing an integrative perspec-
tive for counseling practice. I also present a framework to help you begin to integrate
concepts and techniques from various approaches. As you read, start to formulate
your own personal perspective for counseling. Look for ways to synthesize diverse
elements from different theoretical perspectives. As much as possible, be alert to
how these systems can function in harmony.
Visit CengageBrain.com or watch the DVD for the video program on Chapter 15, Theory and
Practice of Counseling and Psychotherapy: The Case of Stan and Lecturettes. I suggest that you view the
brief lecture for each chapter prior to reading the chapter.
The Movement Toward Psychotherapy Integration
A large number of therapists identify themselves as “eclectic,” and this category
covers a broad range of practice. At its worst, eclectic practice consists of haphaz-
ardly picking techniques without any overall theoretical rationale. This is known
as syncretism, wherein the practitioner, lacking in knowledge and skill in selecting
interventions, looks for anything that seems to work, often making little attempt to
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A N I N T E g R AT I V E P E R s P E C T I V E 429
determine whether the therapeutic procedures are indeed effective. Such an uncriti-
cal and unsystematic combination of techniques is no better than a narrow and
dogmatic orthodoxy. Pulling techniques from many sources without a sound ratio-
nale results in syncretistic confusion, which is detrimental to the successful treat-
ment of clients (Corey, 2015; Neukrug, 2016; Norcross & Beutler, 2014).
Pathways Toward Psychotherapy Integration
Psychotherapy integration is best characterized by attempts to look beyond
and across the confines of single-school approaches to see what can be learned from
other perspectives and how clients can benefit from a variety of ways of conduct-
ing therapy. The majority of psychotherapists do not claim allegiance to a particular
therapeutic school but prefer, instead, some form of integration (Norcross, 2005;
Norcross & Beutler, 2014). In a 2007 survey, only 4.2% of respondents identified
themselves as being aligned with one therapy model exclusively. The remaining 95.8%
claimed to be integrative, meaning they combined a variety of methods or approaches
in their counseling practice (Psychotherapy Networker, 2007). A panel of psychotherapy
experts has predicted an increase in the popularity of integrative therapies in the next
decade, particularly with regard to mindfulness, cognitive behavioral, multicultural,
and integrative theories (Norcross, Pfund, & Prochaska, 2013).
The integrative approach is characterized by openness to various ways of inte-
grating diverse theories and techniques, and there is a decided preference for the
term integrative over eclectic (Norcross, Karpiak, & Lister, 2005). The ultimate goal of
integration is to enhance the efficiency and applicability of psychotherapy. Norcross
and Beutler (2014) and Stricker (2010) describe four of the most common path-
ways toward the integration of psychotherapies: technical integration, theoretical
integration, assimilative integration, and common factors approach. All of these
approaches to integration look beyond the restrictions of single approaches, but
they do so in distinctive ways.
technical integration aims at selecting the best treatment techniques for the
individual and the problem. It tends to focus on differences, chooses from many
approaches, and is a collection of techniques. This path calls for using techniques
from different schools without necessarily subscribing to the theoretical positions
that spawned them. For those who practice from the perspective of technical inte-
gration, there is no necessary connection between conceptual foundations and tech-
niques. Therapists have a variety of tools in their toolkit to use with clients. One
of the best-known forms of technical integration, which Lazarus (2008a) refers to
as technical eclecticism, is the basis of multimodal therapy. Multimodal therapists bor-
row from many other therapeutic models, using techniques that have been demon-
strated to be effective in dealing with specific clinical problems. Whenever feasible,
multimodal therapists employ empirically supported techniques.
In contrast, theoretical integration refers to a conceptual or theoretical cre-
ation beyond a mere blending of techniques. This route has the goal of producing a
conceptual framework that synthesizes the best aspects of two or more theoretical
approaches under the assumption that the outcome will be richer than either the-
ory alone. This approach emphasizes integrating the underlying theories of therapy
along with techniques from each. Examples of this form of integration are dialectical
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430 C H A P T E R F I F T E E N
behavior therapy (DBT) and acceptance and commitment therapy (ACT), both of which
are described in Chapter 9.
Emotion-focused therapy (EFT), introduced in Chapter 7, is another form of
theoretical integration. This approach is informed by the role of emotion in psy-
chotherapeutic change. Greenberg (2011), a key figure in the development of EFT,
conceptualizes the model as an empirically supported, integrative, experiential
approach to treatment. Emotion-focused therapy is rooted in a person-centered
philosophy, but it is integrative in that it synthesizes aspects of Gestalt therapy,
experiential therapy, and existential therapy. Emotion-focused therapy blends the
relational aspects of the person-centered approach with the active phenomenologi-
cal awareness experiments of Gestalt therapy.
The assimilative integration approach is grounded in a particular school of
psychotherapy, along with an openness to selectively incorporate practices from
other therapeutic approaches. Assimilative integration combines the advantages of
a single coherent theoretical system with the flexibility of a variety of interventions
from multiple systems. An example of this form of integration is mindfulness-based
cognitive therapy (MBCT), which integrates aspects of cognitive therapy and mindful-
ness-based stress reduction procedures. As you may recall from Chapter 9, MBCT
is a comprehensive integration of the principles and skills of mindfulness that has
been applied to the treatment of depression (Segal, Williams, & Teasdale, 2013).
The common factors approach searches for common elements across differ-
ent theoretical systems. Despite many differences among the theories, a recogniz-
able core of counseling practice is composed of nonspecific variables common to all
therapies. Lambert (2011) concludes that common factors can be a basis for psycho-
therapy integration:
The common factors explanation for the general equivalence of diverse therapeu-
tic interventions has resulted in the dominance of integrative practice in routine
care by implying that the dogmatic advocacy of a particular theoretical school is
not supported by research. Research also suggests that common factors can become
the focal point for integration of seemingly diverse therapy techniques. (p. 314)
Some of these common factors include empathic listening, support, warmth,
developing a working alliance, opportunity for catharsis, practicing new behaviors,
feedback, positive expectations of clients, working through one’s own conflicts,
understanding interpersonal and intrapersonal dynamics, change that occurs
outside of the therapy office, client factors, therapist effects, and learning to be
self-reflective about one’s work (Norcross & Beutler, 2014; Prochaska & Norcross,
2014).These common factors are thought to be far more important in account-
ing for therapeutic outcomes than the unique factors that differentiate one theory
from another. Specific treatment techniques make relatively little difference in
outcome when compared with the value of common factors, especially the human
elements (Elkins, 2016). Among the approaches to psychotherapy integration, the
common factors approach has the strongest empirical support (Duncan, Miller,
Wampold, & Hubble, 2010).
Of all of the common factors investigated in psychotherapy, none has received
more attention and confirmation than a facilitative therapeutic relationship
(Lambert, 2011). The importance of the therapeutic alliance is a well-established
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A N I N T E g R AT I V E P E R s P E C T I V E 431
critical component of effective therapy. Research confirms that the client–therapist
relationship is central to therapeutic change and is a significant predictor of both
effectiveness and retention of therapy outcomes (Elkins, 2016; Miller, Hubble, &
Seidel, 2015).
Advantages of Psychotherapy Integration
An integrative approach provides a general framework that enables practi-
tioners to make sense of the many aspects of the therapy process and provides a
map giving direction to what practitioners do and say (Corey, 2015). One reason for
the movement toward psychotherapy integration is the recognition that no single
theory is comprehensive enough to account for the complexities of human behav-
ior, especially when the range of client types and their specific problems are taken
into consideration. Because no one theory contains all the truth, and because no
single set of counseling techniques is always effective in working with diverse client
populations, integrative approaches hold promise for counseling practice. Norcross
and Wampold (2011b) maintain that effective clinical practice requires a flexible
and integrative perspective. Psychotherapy should be flexibly tailored to the unique
needs and contexts of the individual client. Norcross and Wampold contend that
using an identical therapy relationship style and treatment method for all clients is
inappropriate and can be unethical.
The 11 systems discussed in this book have evolved in the direction of broad-
ening their theoretical and practical bases and have become less restrictive in their
focus. Many practitioners who claim allegiance to a particular system of therapy
are expanding their theoretical outlook and developing a wider range of therapeu-
tic techniques to fit a more diverse population of clients. There is a growing recog-
nition that psychotherapy can be most effective when contributions from various
approaches are integrated (Goldfried, Glass, & Arnkoff, 2011). Although to date
the bulk of psychotherapy integration has been based on theoretical and clinical
foundations, Goldfried and colleagues suggest that evidence-based practice will
increasingly become the organizing force for integration. Empirical pragmatism,
not theory, will be the integrative theme of the 21st century.
Practitioners who are open to an integrative perspective will find that several
theories play a crucial role in their personal counseling approach. Each theory has
its unique contributions and its own domain of expertise. By accepting that each
theory has strengths and weaknesses and is, by definition, “different” from the oth-
ers, practitioners have some basis to begin developing a theory that fits for them
and their clients. It takes considerable time to learn the various theories in depth. It
is not realistic for any of us to expect that we can integrate all the theories. Instead,
integration of some aspects of some theories is a more realistic goal. Developing an
integrative perspective is a lifelong endeavor that is refined with clinical experience,
reflection, reading, and discourse with colleagues.
The Challenge of Developing an Integrative Perspective
A survey of approaches to counseling and psychotherapy reveals that no
common philosophy unifies them. Many of the theories have different basic phi-
losophies and views of human nature (Table 15.1). As the postmodern therapists
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432 C H A P T E R F I F T E E N
TAbLe 15.1 The basic Philosophies
Psychoanalytic
therapy
Human beings are basically determined by psychic energy and by early experiences. Unconscious
motives and conflicts are central in present behavior. Early development is of critical importance
because later personality problems have their roots in repressed childhood conflicts.
Adlerian
therapy
Humans are motivated by social interest, by striving toward goals, by inferiority and superiority, and
by dealing with the tasks of life. Emphasis is on the individual’s positive capacities to live in society
cooperatively. People have the capacity to interpret, influence, and create events. Each person at an
early age creates a unique style of life, which tends to remain relatively constant throughout life.
Existential
therapy
The central focus is on the nature of the human condition, which includes a capacity for self-
awareness, freedom of choice to decide one’s fate, responsibility, anxiety, the search for meaning,
being alone and being in relation with others, striving for authenticity, and facing living and dying.
Person-centered
therapy
Positive view of people; we have an inclination toward becoming fully functioning. In the context of
the therapeutic relationship, the client experiences feelings that were previously denied to awareness.
The client moves toward increased awareness, spontaneity, trust in self, and inner-directedness.
Gestalt therapy The person strives for wholeness and integration of thinking, feeling, and behaving. Some key
concepts include contact with self and others, contact boundaries, and awareness. The view is
nondeterministic in that the person is viewed as having the capacity to recognize how earlier
influences are related to present difficulties. As an experiential approach, it is grounded in the here
and now and emphasizes awareness, personal choice, and responsibility.
Behavior
therapy
Behavior is the product of learning. We are both the product and the producer of the environment.
Traditional behavior therapy is based on classical and operant principles. Contemporary behavior
therapy has branched out in many directions, including mindfulness and acceptance approaches.
Cognitive
behavior therapy
Individuals tend to incorporate faulty thinking, which leads to emotional and behavioral disturbances.
Cognitions are the major determinants of how we feel and act. Therapy is primarily oriented toward cognition
and behavior, and it stresses the role of thinking, deciding, questioning, doing, and redeciding. This is a
psychoeducational model, which emphasizes therapy as a learning process, including acquiring and practicing
new skills, learning new ways of thinking, and acquiring more effective ways of coping with problems.
Choice theory/
Reality therapy
Based on choice theory, this approach assumes that we need quality relationships to be happy.
Psychological problems are the result of our resisting control by others or of our attempt to control
others. Choice theory is an explanation of human nature and how to best achieve satisfying
interpersonal relationships.
Feminist
therapy
Feminists criticize many traditional theories to the degree that they are based on gender-biased
concepts, such as being androcentric, gendercentric, ethnocentric, heterosexist, and intrapsychic. The
constructs of feminist therapy include being gender fair, flexible, interactionist, and life-span-oriented.
Gender and power are at the heart of feminist therapy. This is a systems approach that recognizes the
cultural, social, and political factors that contribute to an individual’s problems.
Postmodern
approaches
Based on the premise that there are multiple realities and multiple truths, postmodern therapies
reject the idea that reality is external and can be grasped. People create meaning in their lives
through conversations with others. The postmodern approaches avoid pathologizing clients, take
a dim view of diagnosis, avoid searching for underlying causes of problems, and place a high value
on discovering clients’ strengths and resources. Rather than talking about problems, the focus of
therapy is on creating solutions in the present and the future.
Family systems
therapy
The family is viewed from an interactive and systemic perspective. Clients are connected to a living
system; a change in one part of the system will result in a change in other parts. The family provides
the context for understanding how individuals function in relationship to others and how they
behave. Treatment deals with the family unit. An individual’s dysfunctional behavior grows out of
the interactional unit of the family and out of larger systems as well.
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A N I N T E g R AT I V E P E R s P E C T I V E 433
remind us, our philosophical assumptions are important because they influence
which “reality” we perceive, and they direct our attention to the variables that we are
“set” to see. A word of caution, then: Beware of subscribing exclusively to any one
view of human nature. Remain open and selectively incorporate a framework for
counseling that is consistent with your own personality and belief system and that
validates clients’ belief systems as well.
Despite the divergences in the various theories, creative syntheses among some
models are possible. For example, an existential orientation does not necessarily pre-
clude using techniques drawn from behavior therapy or from some of the cognitive
theories. Each point of view offers a perspective for helping clients in their search
for self. I encourage you to study all the major theories and to remain open to what
you might take from the various orientations as a basis for an integrative perspective
that will guide your practice.
In developing a personal integrative perspective, it is important to be alert to the
problem of attempting to mix theories with incompatible underlying assumptions.
Examine the key concepts of various theories as you begin to think about integra-
tion (Table 15.2). By remaining theoretically consistent, but technically integrative,
practitioners can spell out precisely the interventions they will employ with various
clients, as well as the means by which they will select these procedures.
TAbLe 15.2 Key Concepts
Psychoanalytic
therapy
Normal personality development is based on successful resolution and integration of psychosexual
stages of development. Faulty personality development is the result of inadequate resolution of
some specific stage. Anxiety is a result of repression of basic conflicts. Unconscious processes are
centrally related to current behavior.
Adlerian
therapy
Key concepts include the unity of personality, the need to view people from their subjective
perspective, and the importance of life goals that give direction to behavior. People are motivated
by social interest and by finding goals to give life meaning. Other key concepts are striving
for significance and superiority, developing a unique lifestyle, and understanding the family
constellation. Therapy is a matter of providing encouragement and assisting clients in changing their
cognitive perspective and behavior.
Existential
therapy
Essentially an experiential approach to counseling rather than a firm theoretical model, it stresses
core human conditions. Interest is on the present and on what one is becoming. The approach has
a future orientation and stresses self-awareness before action.
Person-centered
therapy
The client has the potential to become aware of problems and the means to resolve them. Faith is
placed in the client’s capacity for self-direction. Mental health is a congruence of ideal self and real
self. Maladjustment is the result of a discrepancy between what one wants to be and what one is.
In therapy attention is given to the present moment and on experiencing and expressing feelings.
Gestalt
therapy
Emphasis is on the “what” and “how” of experiencing in the here and now to help clients accept all
aspects of themselves. Key concepts include holism, figure-formation process, awareness, unfinished
business and avoidance, contact, and energy.
Behavior
therapy
Focus is on overt behavior, precision in specifying goals of treatment, development of specific
treatment plans, and objective evaluation of therapy outcomes. Present behavior is given attention.
Therapy is based on the principles of learning theory. Normal behavior is learned through
reinforcement and imitation. Abnormal behavior is the result of faulty learning.
(continued)
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434 C H A P T E R F I F T E E N
One of the challenges you will face as a counselor is to deliver therapeutic ser-
vices in a brief, comprehensive, effective, and flexible way. Many of the theoretical
orientations addressed in this book can be applied to brief forms of therapy. One of
the driving forces of the psychotherapy integration movement has been the increase
of brief therapies and the pressures to do more for a variety of client populations
within the limitations of 6 to 20 sessions. Short-term and very-short-term therapies
are increasing (Norcross et al., 2013). Time-limited brief therapy refers to a variety
of time-sensitive, goal-directed, efficiency-oriented methods. These methods can be
incorporated in any theoretical approach (Hoyt, 2015). Lambert (2011) believes the
future direction of theory, practice, and training will see (1) the decline of single-
theory practice and the growth of integrative therapies, and (2) the increase in short-
term, time-limited, and group treatments that seem to be as effective as long-term
individual treatments with many client populations.
An integrative perspective at its best entails a systematic integration of underly-
ing principles and methods common to a range of therapeutic approaches. The
strengths of systematic integration are based on its ability to be taught, replicated,
and evaluated (Norcross & Beutler, 2014). To develop this kind of integration, you
will eventually need to be thoroughly conversant with a number of theories, be open
to the idea that these theories can be connected in some ways, and be willing to
continually test your hypotheses to determine how well they are working. Neukrug
(2016) reminds us that “the ability to assimilate techniques from varying theoretical
perspectives takes knowledge, time, and finesse” (p. 139).
Cognitive behavior
therapy
Although psychological problems may be rooted in childhood, they are reinforced by present
ways of thinking. A person’s belief system and thinking is the primary cause of disorders. Internal
dialogue plays a central role in one’s behavior. Clients focus on examining faulty assumptions and
misconceptions and on replacing these with effective beliefs.
Choice theory/
Reality therapy
The basic focus is on what clients are doing and how to get them to evaluate whether their present
actions are working for them. People are mainly motivated to satisfy their needs, especially the need
for significant relationships. The approach rejects the medical model, the notion of transference, the
unconscious, and dwelling on one’s past.
Feminist
therapy
Core principles of feminist therapy are that the personal is political, therapists have a commitment
to social change, women’s voices and ways of knowing are valued and women’s experiences are
honored, the counseling relationship is egalitarian, therapy focuses on strengths and a reformulated
definition of psychological distress, and all types of oppression are recognized.
Postmodern
approaches
Therapy tends to be brief and addresses the present and the future. The person is not the problem;
the problem is the problem. The emphasis is on externalizing the problem and looking for
exceptions to the problem. Therapy consists of a collaborative dialogue in which the therapist and
the client co-create solutions. By identifying instances when the problem did not exist, clients can
create new meanings for themselves and fashion a new life story.
Family systems
therapy
Focus is on communication patterns within a family, both verbal and nonverbal. Problems in
relationships are likely to be passed on from generation to generation. Key concepts vary depending
on specific orientation but include differentiation, triangles, power coalitions, family-of-origin
dynamics, functional versus dysfunctional interaction patterns, and dealing with here-and-now
interactions. The present is more important than exploring past experiences.
TAbLe 15.2 Key Concepts (continued)
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A N I N T E g R AT I V E P E R s P E C T I V E 435
Integration of Multicultural Issues in Counseling
Multiculturalism is a reality that cannot be ignored by practitioners if they
hope to meet the needs of diverse client groups. I believe current theories, to varying
degrees, can and should be expanded to incorporate a multicultural dimension. I
have consistently pointed out that if contemporary theories do not account for the
cultural dimension, they will have limited applicability in working with diverse cli-
ent populations. For some theories, this transition is easier than for others.
Clients can be harmed if they are expected to fit all the specifications of a given
theory, whether or not the values espoused by the theory are consistent with their own
cultural values. Rather than stretching the client to fit the dimensions of a single theory,
practitioners need to tailor their theory and practice to fit the unique needs of the client.
This calls for counselors to possess knowledge of various cultures, to be aware of their
own cultural heritage, and to have skills to assist a wide spectrum of clients in dealing
with the realities of their culture. Psychotherapy integration stresses tailoring interven-
tions to the individual client rather than to an overarching theory, making this approach
particularly well suited to considering cultural factors and the unique perspective of
each client. Comas-Diaz (2014) believes that cultural competence enables counselors to
work effectively in most clinical settings. Practitioners demonstrate their cultural com-
petence by becoming aware of their own and their clients’ worldviews, and by being able
to use culturally appropriate interventions to reflect their cultural beliefs, knowledge,
and skills. This is a good time to review the discussion of the culturally skilled counselor
in Chapter 2 and to consult Tables 15.7 and 15.8, which appear later in this chapter.
In your role as a counselor, you need to be able to assess the special needs of
clients. The client’s ethnicity and culture and the concerns that bring this person to
counseling challenge you to develop flexibility in utilizing an array of therapeutic
strategies. Some clients will need more direction and guidance; others will be hesitant
to talk about themselves in personal ways, especially during the early phase of the
counseling process. What you may see as resistance could be the client’s response to
years of cultural conditioning and respect for certain values and traditions. Basically,
it comes down to your familiarity with a variety of theoretical approaches and your
ability to employ and adapt your techniques to fit the person-in-the-environment. It
is not enough to merely assist your clients in gaining insight, expressing suppressed
emotions, or making certain behavioral changes. The challenge is to find practical
strategies for adapting the techniques you have developed to enable clients to exam-
ine the impact their culture continues to have on their lives and to make decisions
about what, if anything, they want to change.
Being an effective counselor involves reflecting on how your own culture influ-
ences you and your interventions in your counseling practice. This awareness is
critical in becoming more sensitive to the cultural backgrounds of the clients who
seek your help. Using an integrative perspective, therapists can encompass social,
cultural, spiritual, and political dimensions in their work with clients.
Integration of Spirituality and Religion in Counseling
The counseling process can help clients gain insight into the ways their core
beliefs and values are reflected in their behavior. Current interest in spiritual and
religious beliefs has implications for how such beliefs might be incorporated in
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436 C H A P T E R F I F T E E N
therapeutic relationships (Frame, 2003; Johnson, 2013; Young & Cashwell, 2011a).
Survey data from members of both the American Psychological Association and
the American Counseling Association indicate that spiritual and religious matters
are therapeutically relevant, ethically appropriate, and potentially significant topics
for the practice of counseling in secular settings (Delaney, Miller, & Bisono, 2007;
Young, Wiggins-Frame, & Cashwell, 2007).
Worthington (2011) asserts that the increasing openness of therapists to cli-
ents’ spiritual and religious concerns and interests has been fueled by the multicul-
tural evolution. The emphasis on multiculturalism has empowered people to define
themselves from a cultural perspective, which includes their spiritual, religious, and
ethnic contexts. Johnson (2013) views spiritually informed therapy as a form of mul-
ticultural therapy. The first step is for the therapist to be sincerely interested in the
client’s spiritual beliefs and experiences and how he or she finds meaning in life.
Johnson believes that a client-defined sense of spirituality can be a significant avenue
for connecting with the client and can be an ally in the therapeutic change process.
However, the emphasis is on what the client wants, not on the therapist’s spiritual
experiences or agenda for the client.
Clients who are experiencing a crisis situation may find a source of comfort,
support, and strength in drawing upon their spiritual resources. For some clients
spirituality entails embracing a religion, which can have many different meanings.
Other clients value spirituality, yet do not have any ties to a formal religion. What-
ever one’s particular view of spirituality, it is a force that can help the individual to
find a purpose (or purposes) for living. Spiritual or religious beliefs can be a major
sustaining power that supports clients when all else fails. Other clients may be
affected by depression and a sense of worthlessness due to guilt, anger, or sadness
created by their unexamined acceptance of spiritual or religious dogma. Counselors
must remain open and nonjudgmental in conversations about religion or spiritual-
ity. Furthermore, counselors cannot ignore a client’s spiritual and religious perspec-
tives if they want to practice in a culturally competent and ethical manner (Johnson,
2013; Young & Cashwell, 2011a, 2011b). It is essential for counselors to be aware of
and understand their spiritual or religious attitudes, beliefs, values, and experiences
if they expect to facilitate an exploration of these issues with clients.
Common Goals Spiritual values have a major part to play in human life and
struggles. Exploring these values has a great deal to do with providing solutions for
clients’ struggles. Because spiritual and therapeutic paths converge in some ways,
integration is possible, and dealing with a client’s spirituality will often enhance the
therapy process. Themes that have healing influences include loving, caring, learning
to listen with compassion, challenging clients’ basic life assumptions, accepting
human imperfection, and going outside of self-oriented interests (social interest).
Both a spiritual perspective and counseling can help people ponder questions of “Who
am I?” and “What is the meaning of my life?” Pursuing these existential questions can
foster healing.
Implications for Assessment and Treatment Traditionally, when clients come
to a therapist with a problem, the therapist explores all the factors that contributed
to the development of the problem. A background of involvement in religion can be
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A N I N T E g R AT I V E P E R s P E C T I V E 437
part of a client’s history, and thus it can be a part of the intake assessment and can be
explored in counseling sessions. Frame (2003) presents many reasons for including
spirituality in the assessment process: understanding clients’ worldviews and the
contexts in which they live, assisting clients in grappling with questions regarding the
purpose of their lives and what they most value, exploring religion and spirituality as
client resources, and uncovering religious and spiritual problems. This information
will assist the therapist in choosing appropriate interventions. Young and Cashwell
(2011a) maintain that counselors must assess whether clients’ spiritual or religious
beliefs may be exacerbating or helping clients’ psychological problems.
Your Role as a Counselor It is critical that counselors not be judgmental when it
comes to their clients’ beliefs and that counselors create an inviting and safe climate
for clients to explore their values and beliefs. There are many paths toward fulfilling
spiritual needs, and it is not your role as a counselor to prescribe any particular
pathway. By conducting a thorough assessment on a client’s background, you will
obtain many clues regarding personal themes for potential exploration. If you
remain finely tuned to clients’ stories and to the purpose for which they sought
therapy, clients’ concerns about spiritual or religious values, beliefs, and practices
will surface. It is critical that you listen for how clients talk about existential
concerns of meaning, values, mortality, and being in the world. Remain open to
how your clients define, experience, and access whatever helps them stay connected
to their core values and their inner wisdom (Johnson, 2013).
If you are to effectively serve diverse client populations, it is essential that you
pay attention to your training and competence in addressing spiritual and religious
concerns your clients bring to therapy. Ethically, it is important to monitor yourself
for subtle ways that you might be inclined to influence clients to embrace a spiritual
perspective or to give up certain religious beliefs that you think are no longer func-
tional for them. It is important to keep in mind that clients, not therapists, should
determine the specific values they want to retain, replace, or modify.
From my vantage point, the emphasis on spirituality will continue to be impor-
tant in counseling practice, which makes it imperative that you prepare yourself to
work competently with the spiritual and religious concerns that your clients bring
up. For further reading on the topic of integrating spirituality and religion into
counseling, I highly recommend Integrating Spirituality and Religion into Counseling: A
Guide to Competent Practice (Cashwell & Young, 2011) and Spirituality in Counseling and
Psychotherapy: An Integrative Approach That Empowers Clients (Johnson, 2013).
Issues Related to the Therapeutic Process
Therapeutic Goals
The goals of counseling are almost as diverse as are the theoretical approaches
(Table 15.3). Some possible goals include the following:
�� Restructuring the personality
�� Uncovering the unconscious
�� Creating social interest
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438 C H A P T E R F I F T E E N
�� Finding meaning in life
�� Curing an emotional disturbance
�� Examining old decisions and making new ones
�� Developing trust in oneself
�� Becoming more self-actualizing
TAbLe 15.3 Goals of Therapy
Psychoanalytic
therapy
To make the unconscious conscious. To reconstruct the basic personality. To assist clients in reliving
earlier experiences and working through repressed conflicts. To achieve intellectual and emotional
awareness.
Adlerian
therapy
To challenge clients’ basic premises and life goals. To offer encouragement so individuals can develop
socially useful goals and increase social interest. To develop the client’s sense of belonging.
Existential
therapy
To help people see that they are free and to become aware of their possibilities. To challenge them to
recognize that they are responsible for events that they formerly thought were happening to them.
To identify factors that block freedom.
Person-centered
therapy
To provide a safe climate conducive to clients’ self-exploration. To help clients recognize blocks to
growth and experience aspects of self that were formerly denied or distorted. To enable them to
move toward openness, greater trust in self, willingness to be a process, and increased spontaneity
and aliveness. To find meaning in life and to experience life fully. To become more self-directed.
Gestalt
therapy
To assist clients in gaining awareness of moment-to-moment experiencing and to expand the
capacity to make choices. To foster integration of the self.
Behavior
therapy
To eliminate maladaptive behaviors and learn more effective behaviors. To identify factors that
influence behavior and find out what can be done about problematic behavior. To encourage clients
to take an active and collaborative role in clearly setting treatment goals and evaluating how well
these goals are being met.
Cognitive behavior
therapy
To teach clients to confront faulty beliefs with contradictory evidence that they gather and evaluate.
To help clients seek out their faulty beliefs and minimize them. To become aware of automatic
thoughts and to change them. To assist clients in identifying their inner strengths, and to explore the
kind of life they would like to have.
Choice theory/
Reality therapy
To help people become more effective in meeting all of their psychological needs. To enable clients
to get reconnected with the people they have chosen to put into their quality worlds and teach
clients choice theory.
Feminist
therapy
To bring about transformation both in the individual client and in society. To assist clients in recognizing,
claiming, and using their personal power to free themselves from the limitations of gender-role
socialization. To confront all forms of institutional policies that discriminate or oppress on any basis.
Postmodern
approaches
To change the way clients view problems and what they can do about these concerns. To
collaboratively establish specific, clear, concrete, realistic, and observable goals leading to increased
positive change. To help clients create a self-identity grounded on competence and resourcefulness
so they can resolve present and future concerns. To assist clients in viewing their lives in positive
ways, rather than being problem saturated.
Family systems
therapy
To help family members gain awareness of patterns of relationships that are not working well and to
create new ways of interacting. To identify how a client’s problematic behavior may serve a function
or purpose for the family. To understand how dysfunctional patterns can be handed down across
generations. To recognize how family rules can affect each family member. To understand how past
family of origin experiences continue to have an impact on individuals.
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A N I N T E g R AT I V E P E R s P E C T I V E 439
�� Reducing maladaptive behavior and learning adaptive patterns
�� Becoming grounded in the present moment
�� Managing intense emotions such as anxiety
�� Gaining more effective control of one’s life
�� Reauthoring the story of one’s life
This diversity can be simplified by considering the degree of generality or speci-
ficity of goals. Goals exist on a continuum from specific, concrete, and short term
on one end, to general, global, and long term on the other. The cognitive behavioral
approaches stress the former; the relationship-oriented therapies tend to stress the
latter. The goals at opposite ends of the continuum are not necessarily contradic-
tory; it is a matter of how specifically they are defined.
Therapist’s Function and Role
In working toward an integrative perspective, ask yourself these questions:
�� How do the counselor’s functions change depending on the stage of the
counseling process?
�� Does the therapist maintain a basic role, or does this role vary in accor-
dance with the characteristics of the client?
�� How does the counselor determine how active and directive to be?
�� How is structuring handled as the course of therapy progresses?
�� What is the optimum balance of responsibility in the client–therapist
relationship?
�� What is the most effective way to monitor the therapeutic alliance?
�� What, when, and how much counselor self-disclosure is therapeutic?
As you saw through your study of the 11 therapeutic approaches, a central issue
of each system is the degree to which the therapist exercises control over clients’
behavior both during and outside the session. Cognitive behavior therapists and
reality therapists, for example, operate within a present-centered, directive, didac-
tic, structured, and psychoeducational context. As a collaborative endeavor, they
frequently design homework assignments to assist clients in practicing new behav-
ior outside therapy sessions. In contrast, person-centered therapists operate with a
much looser and less defined structure. Solution-focused and narrative therapists
view the client as the expert on his or her own life; they assist the client in reflection
outside of the session that might result in self-directed change. Although they are
active questioners, they are not prescriptive in their practice.
Structuring depends on the particular client and the specific circumstances
he or she brings to the therapy situation. From my perspective, clear structure
is most essential during the early phase of counseling because it encourages the
client to talk about the problems that led to seeking therapy. In a collaborative
way, it is useful for both counselor and client to make some initial assessment
that can provide a focus for the therapy process. As soon as possible, the client
should be given a significant share of the responsibility for deciding on the con-
tent and agenda of the sessions. From early in the therapy process the client can
be empowered if the counselor expects the client to become an active participant
in the process.
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440 C H A P T E R F I F T E E N
Client’s Experience in Therapy
Most clients share some degree of suffering, pain, or at least discontent. There is
a discrepancy between how they would like to be and how they are. Some individu-
als initiate therapy because they hope to cure a specific symptom or set of symptoms.
They want to get rid of migraine headaches, free themselves of chronic anxiety attacks,
lose weight, or get relief from depression. They may have conflicting feelings and reac-
tions, may struggle with low self-esteem, or may have limited information and
skills. Many seek to resolve conflicts in their close relationships. I believe people
are increasingly entering therapy with existential problems. Their complaints often
relate to the these existential issues: a sense of emptiness, meaninglessness in life,
routine ways of living, unsatisfying personal relationships, anxiety over uncertainty,
a lack of intense feelings, and a loss of their sense of self.
The initial expectation of many clients is that results will come quickly. They
often have great hope for major changes in their life and rely on direction from the
therapist. As therapy progresses, clients discover that they must be active in the pro-
cess, selecting their own goals and working toward them, both in the sessions and in
daily living. Some clients can benefit from recognizing and expressing pent-up feel-
ings, others will need to examine their beliefs and thoughts, others will most need
to begin behaving in different ways, and others will benefit from talking with you
about their relationships with the significant people in their lives. Most clients will
need to do some work in all three dimensions—feelings, thoughts, and behaviors—
because these dimensions are interrelated.
In deciding what interventions are most likely to be helpful, it is important
to take into account the client’s cultural, ethnic, and socioeconomic background.
Moreover, the focus of counseling may change as clients enter different phases in the
counseling process. Although some clients initially feel a need to be listened to and
allowed to express deep feelings, they can profit later from examining the thought
patterns that are contributing to their psychological pain. A some point in therapy,
it is essential that clients translate what they are learning about themselves into con-
crete action. The client’s given situation in the environment provides a framework
for selecting interventions that are most appropriate.
Relationship Between Therapist and Client
Most approaches share common ground in accepting the importance of the thera-
peutic relationship. The existential, person-centered, Gestalt, Adlerian, and post-
modern views emphasize the personal relationship as the crucial determinant of
treatment outcomes. Rational emotive behavior therapy, reality therapy, cognitive
behavior therapy, cognitive therapy, and behavior therapy do not ignore the rela-
tionship factor but place less emphasis on the relationship and more emphasis on
the effective use of techniques (Table 15.4).
Counseling is a personal matter that involves a personal relationship, and evi-
dence indicates that honesty, sincerity, acceptance, understanding, and spontane-
ity are basic ingredients for successful outcomes. Therapists’ degree of caring, their
interest and ability in helping their clients, and their genuineness influence the
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A N I N T E g R AT I V E P E R s P E C T I V E 441
TAbLe 15.4 The Therapeutic Relationship
Psychoanalytic
therapy
The classical analyst remains anonymous, and clients develop projections toward him or her. The
focus is on reducing the resistances that develop in working with transference and on establishing
more rational control. Clients undergo long-term analysis, engage in free association to uncover
conflicts, and gain insight by talking. The analyst makes interpretations to teach clients the
meaning of current behavior as it relates to the past. In contemporary relational psychoanalytic
therapy, the relationship is central and emphasis is given to here-and-now dimensions of this
relationship.
Adlerian
therapy
The emphasis is on joint responsibility, on mutually determining goals, on mutual trust and respect,
and on equality. The focus is on identifying, exploring, and disclosing mistaken goals and faulty
assumptions within the person’s lifestyle.
Existential
therapy
The therapist’s main tasks are to accurately grasp clients’ being in the world and to establish a
personal and authentic encounter with them. The immediacy of the client–therapist relationship
and the authenticity of the here-and-now encounter are stressed. Both client and therapist can be
changed by the encounter.
Person-centered
therapy
The relationship is of primary importance. The qualities of the therapist, including genuineness,
warmth, accurate empathy, respect, and being nonjudgmental—and communication of these
attitudes to clients—are stressed. Clients use this genuine relationship with the therapist to help
them transfer what they learn to other relationships.
Gestalt
therapy
Central importance is given to the I/Thou relationship and the quality of the therapist’s presence.
The therapist’s attitudes and behavior count more than the techniques used. The therapist does not
interpret for clients but assists them in developing the means to make their own interpretations.
Clients identify and work on unfinished business from the past that interferes with current
functioning.
Behavior
therapy
The therapist is active and directive and functions as a teacher or mentor in helping clients learn
more effective behavior. Clients must be active in the process and experiment with new behaviors.
Although a quality client–therapist relationship is not viewed as sufficient to bring about change,
it is considered essential for implementing behavioral procedures.
Cognitive behavior
therapy
In REBT the therapist functions as a teacher and the client as a student. The therapist is highly
directive and teaches clients an A-B-C model of changing their cognitions. In CT the focus is on
a collaborative relationship. Using a Socratic dialogue, the therapist assists clients in identifying
dysfunctional beliefs and discovering alternative rules for living. The therapist promotes corrective
experiences that lead to learning new skills. Clients gain insight into their problems and then
must actively practice changing self-defeating thinking and acting. In strengths-based CBT, active
incorporation of client strengths encourages full engagement in therapy and often provides avenues
for change that otherwise would be missed.
Choice theory/
Reality therapy
A fundamental task is for the therapist to create a good relationship with the client. Therapists are
then able to engage clients in an evaluation of all of their relationships with respect to what they
want and how effective they are in getting this. Therapists find out what clients want, ask what they
are choosing to do, invite them to evaluate present behavior, help them make plans for change, and
get them to make a commitment. The therapist is a client’s advocate, as long as the client is willing
to attempt to behave responsibly.
Feminist
therapy
The therapeutic relationship is based on empowerment and egalitarianism. Therapists actively
break down the hierarchy of power and reduce artificial barriers by engaging in appropriate self-
disclosure and teaching clients about the therapy process. Therapists strive to create a collaborative
relationship in which clients can become their own expert.
(continued)
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442 C H A P T E R F I F T E E N
relationship. Therapists can become more effective by developing their personal
qualities and their interpersonal abilities. Psychotherapy is primarily a human and
relational endeavor that depends on the quality of the interpersonal connection
between participants (Duncan, 2014; Elkins, 2016). Both client and therapist bring
origins, culture, expectations, biases, defenses, and strengths to this relationship.
How we create and nurture this powerful human relationship can be guided by the
fruits of research (Norcross & Wampold, 2011a).
As you think about developing your personal counseling perspective, give con-
sideration to the issue of the match between client and counselor. I certainly do
not advocate changing your personality to fit your perception of what each client
is expecting; it is important that you be yourself as you meet clients. You also need
to consider the reality that you will probably not be able to work effectively with
every client. Some clients will work better with counselors who have another type of
personal and therapeutic style than yours. Be sensitive in assessing what your client
needs, and use good judgment when determining the appropriateness of the match
between you and a potential client.
Although you do not have to be like your clients or have experienced the same prob-
lems to be effective with them, it is critical that you be able to understand their world
and respect them. Ask yourself how well prepared you are to counsel clients from a dif-
ferent cultural background. To what degree do you think you can successfully estab-
lish a therapeutic relationship with a client of a different race? Ethnic group? Gender?
Age? Sexual orientation? Spiritual/religious orientation? Socioeconomic group? Do
you see any potential barriers that would make it difficult for you to form a working
relationship with certain clients? It is also important to consider the client’s diagnosis,
resistance level, treatment preferences, and stage of change. Therapeutic techniques
and styles should be selected to fit the client’s personal characteristics. Norcross and
Beutler (2014) suggest that therapists create a new therapy for each client:
We believe that the purpose of integrative psychotherapy is not to create a single
or unitary treatment. Rather, we select different treatment methods according to
the patient and the context. The result is a more efficient and efficacious therapy—
and one that fits both the client and the clinician. (p. 502)
Postmodern
approaches
Therapy is a collaborative partnership. Clients are viewed as the experts on their own life. Therapists
use questioning dialogue to help clients free themselves from their problem-saturated stories and
create new life-affirming stories. Solution-focused therapists assume an active role in guiding the
client away from problem-talk and toward solution-talk. Clients are encouraged to explore their
strengths and to create solutions that will lead to a richer future. Narrative therapists assist clients in
externalizing problems and guide them in examining self-limiting stories and creating new and more
liberating stories.
Family systems
therapy
The family therapist functions as a teacher, coach, model, and consultant. The family learns ways to
detect and solve problems that are keeping members stuck, and it learns about patterns that have
been transmitted from generation to generation. Some approaches focus on the role of therapist
as expert; others concentrate on intensifying what is going on in the here and now of the family
session. All family therapists are concerned with the process of family interaction and teaching
patterns of communication.
TAbLe 15.4 The Therapeutic Relationship (continued)
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A N I N T E g R AT I V E P E R s P E C T I V E 443
The Place of Techniques and Evaluation in Counseling
Drawing on Techniques From Various Approaches
Effective therapists incorporate a wide range of procedures in their thera-
peutic style. Much depends on the purpose of therapy, the setting, the personality
and style of the therapist, the qualities of the particular client, and the problems
selected for intervention. Regardless of the therapeutic model you may be working
with, you must decide what relationship style to adopt; what techniques, procedures,
or intervention methods to use; when to use them; and with which clients. Take time
to review Table 15.5 on therapeutic techniques and Table 15.6 on applications for
LO6
TAbLe 15.5 Techniques of Therapy
Psychoanalytic
therapy
The key techniques are interpretation, dream analysis, free association, analysis of resistance, analysis
of transference, and countertransference. Techniques are designed to help clients gain access to their
unconscious conflicts, which leads to insight and eventual assimilation of new material by the ego.
Adlerian
therapy
Adlerians pay more attention to the subjective experiences of clients than to using techniques. Some
techniques include gathering life-history data (family constellation, early recollections, personal
priorities), sharing interpretations with clients, offering encouragement, and assisting clients in
searching for new possibilities.
Existential
therapy
Few techniques flow from this approach because it stresses understanding first and technique
second. The therapist can borrow techniques from other approaches and incorporate them in an
existential framework. Diagnosis, testing, and external measurements are not deemed important.
Issues addressed are freedom and responsibility, isolation and relationships, meaning and
meaninglessness, living and dying.
Person-centered
therapy
This approach uses few techniques but stresses the attitudes of the therapist and a “way of being.”
Therapists strive for active listening, reflection of feelings, clarification, “being there” for the client,
and focusing on the moment-to-moment experiencing of the client. This model does not include
diagnostic testing, interpretation, taking a case history, or questioning or probing for information.
Gestalt
therapy
A wide range of experiments are designed to intensify experiencing and to integrate conflicting
feelings. Experiments are co-created by therapist and client through an I/Thou dialogue. Therapists
have latitude to creatively invent their own experiments. Formal diagnosis and testing are not a
required part of therapy.
Behavior
therapy
The main techniques are reinforcement, shaping, modeling, systematic desensitization, relaxation
methods, flooding, eye movement and desensitization reprocessing, cognitive restructuring, social
skills training, self-management programs, mindfulness and acceptance methods, behavioral
rehearsal, and coaching. Diagnosis or assessment is done at the outset to determine a treatment
plan. Questions concentrate on “what,” “how,” and “when” (but not “why”). Contracts and
homework assignments are also typically used.
Cognitive behavior
therapy
Therapists use a variety of cognitive, emotive, and behavioral techniques; diverse methods are tailored
to suit individual clients. This is an active, directive, time-limited, present-centered, psychoeducational,
structured therapy. Some techniques include engaging in Socratic dialogue, collaborative empiricism,
debating irrational beliefs, carrying out homework assignments, gathering data on assumptions one
has made, keeping a record of activities, forming alternative interpretations, learning new coping skills,
changing one’s language and thinking patterns, role playing, imagery, confronting faulty beliefs, self-
instructional training, and stress inoculation training.
(continued)
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444 C H A P T E R F I F T E E N
TAbLe 15.6 Applications of the Approaches
Psychoanalytic
therapy
Candidates for analytic therapy include professionals who want to become therapists, people
who have had intensive therapy and want to go further, and those who are in psychological pain.
Analytic therapy is not recommended for self-centered and impulsive individuals or for people with
psychotic disorders. Techniques can be applied to individual and group therapy.
Adlerian
therapy
Because the approach is based on a growth model, it is applicable to such varied spheres of life as
child guidance, parent–child counseling, marital and family therapy, individual counseling with all
age groups, correctional and rehabilitation counseling, group counseling, substance abuse programs,
and brief counseling. It is ideally suited to preventive care and alleviating a broad range of conditions
that interfere with growth.
Existential
therapy
This approach is especially suited to people facing a developmental crisis or a transition in life
and for those with existential concerns (making choices, dealing with freedom and responsibility,
coping with guilt and anxiety, making sense of life, and finding values) or those seeking personal
enhancement. The approach can be applied to both individual and group counseling, and to couples
and family therapy, crisis intervention, and community mental health work.
Person-centered
therapy
Has wide applicability to individual and group counseling. It is especially well suited for the initial
phases of crisis intervention work. Its principles have been applied to couples and family therapy,
community programs, administration and management, and human relations training. It is a useful
approach for teaching, parent–child relations, and for working with groups of people from diverse
cultural backgrounds.
Choice theory/
Reality therapy
This is an active, directive, and didactic therapy. Skillful questioning is a central technique used
for the duration of the therapy process. Various techniques may be used to get clients to evaluate
what they are presently doing to see if they are willing to change. If clients decide that their present
behavior is not effective, they develop a specific plan for change and make a commitment to follow
through.
Feminist
therapy
Although techniques from traditional approaches are used, feminist practitioners tend to employ
consciousness-raising techniques aimed at helping clients recognize the impact of gender-role
socialization on their lives. Other techniques frequently used include gender-role analysis and
intervention, power analysis and intervention, demystifying therapy, bibliotherapy, journal writing,
therapist self-disclosure, assertiveness training, reframing and relabeling, cognitive restructuring,
identifying and challenging untested beliefs, role playing, psychodramatic methods, group work,
and social action.
Postmodern
approaches
In solution-focused therapy the main technique involves change-talk, with emphasis on times
in a client’s life when the problem was not a problem. Other techniques include creative use
of questioning, the miracle question, and scaling questions, which assist clients in developing
alternative stories. In narrative therapy, specific techniques include listening to a client’s
problem-saturated story without getting stuck, externalizing and naming the problem,
externalizing conversations, and discovering clues to competence. Narrative therapists often
write letters to clients and assist them in finding an audience that will support their changes
and new stories.
Family systems
therapy
A variety of techniques may be used, depending on the particular theoretical orientation of the
therapist. Some techniques include genograms, teaching, asking questions, joining the family,
tracking sequences, family mapping, reframing, restructuring, enactments, and setting boundaries.
Techniques may be experiential, cognitive, or behavioral in nature. Most are designed to bring about
change in a short time.
TAbLe 15.5 Techniques of Therapy (continued)
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A N I N T E g R AT I V E P E R s P E C T I V E 445
Gestalt
therapy
Addresses a wide range of problems and populations: crisis intervention, treatment of a range
of psychosomatic disorders, couples and family therapy, awareness training of mental health
professionals, behavior problems in children, and teaching and learning. It is well suited to both
individual and group counseling. The methods are powerful catalysts for opening up feelings and
getting clients into contact with their present-centered experience.
Behavior
therapy
A pragmatic approach based on empirical validation of results. Enjoys wide applicability to
individual, group, couples, and family counseling. Some problems to which the approach is well
suited are phobic disorders, depression, trauma, sexual disorders, children’s behavioral disorders,
stuttering, and prevention of cardiovascular disease. Beyond clinical practice, its principles are
applied in fields such as pediatrics, stress management, behavioral medicine, education, and
geriatrics.
Cognitive behavior
therapy
Has been widely applied to treatment of depression, anxiety, relationship problems, stress
management, skill training, substance abuse, assertion training, eating disorders, panic attacks,
performance anxiety, and social phobias. CBT is especially useful for assisting people in modifying
their cognitions. Many self-help approaches utilize its principles. CBT can be applied to a wide range
of client populations with a variety of specific problems.
Choice theory/
Reality therapy
Geared to teaching people ways of using choice theory in everyday living to increase effective
behaviors. It has been applied to individual counseling with a wide range of clients, group
counseling, working with youthful law offenders, and couples and family therapy. In some instances
it is well suited to brief therapy and crisis intervention.
Feminist
therapy
Principles and techniques can be applied to a range of therapeutic modalities such as individual
therapy, relationship counseling, family therapy, group counseling, and community intervention. The
approach can be applied to both women and men with the goal of bringing about empowerment.
Postmodern
approaches
Solution-focused therapy is well suited for people with adjustment disorders and for problems of
anxiety and depression. Narrative therapy is now being used for a broad range of human difficulties
including eating disorders, family distress, depression, and relationship concerns. These approaches
can be applied to working with children, adolescents, adults, couples, families, and the community
in a wide variety of settings. Both solution-focused and narrative approaches lend themselves to
group counseling and to school counseling.
Family systems
therapy
Useful for dealing with marital distress, problems of communicating among family members, power
struggles, crisis situations in the family, helping individuals attain their potential, and enhancing the
overall functioning of the family.
each approach. Pay careful attention to the focus of each type of therapy and how
that focus might be useful in your practice.
It is critical to be aware of how clients’ cultural backgrounds contribute to their
perceptions of their problems. Each of the 11 therapeutic approaches has both
strengths (Table 15.7) and limitations (Table 15.8) when applied to culturally diverse
client populations. Although it is unwise to stereotype clients because of their cul-
tural heritage, it is useful to assess the bearing cultural context has on their con-
cerns. Some techniques may be contraindicated because of a client’s socialization.
The client’s responsiveness (or lack of it) to certain techniques is a critical barometer
in judging the effectiveness of these methods.
Effective counseling involves proficiency in a combination of cognitive, affec-
tive, and behavioral techniques. Such a combination is necessary to help clients think
about their beliefs and assumptions, to experience on a feeling level their conflicts
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446 C H A P T E R F I F T E E N
TAbLe 15.7 Contributions to Multicultural Counseling
Psychoanalytic
therapy
Its focus on family dynamics is appropriate for working with many cultural groups. The therapist’s
formality appeals to clients who expect professional distance. Notion of ego defense is helpful in
understanding inner dynamics and dealing with environmental stresses.
Adlerian
therapy
Its focus on social interest, helping others, collectivism, pursuing meaning in life, importance of
family, goal orientation, and belonging is congruent with the values of many cultures. Focus on
person-in-the-environment allows for cultural factors to be explored.
Existential
therapy
Focus is on understanding client’s phenomenological world, including cultural background. This approach
leads to empowerment in an oppressive society. Existential therapy can help clients examine their options
for change within the context of their cultural realities. The existential approach is particularly suited to
counseling diverse clients because of the philosophical foundation that emphasizes the human condition.
Person-centered
therapy
Focus is on breaking cultural barriers and facilitating open dialogue among diverse cultural
populations. Main strengths are respect for clients’ values, active listening, welcoming of differences,
nonjudgmental attitude, understanding, willingness to allow clients to determine what will be
explored in sessions, and prizing cultural pluralism.
Gestalt
therapy
Its focus on expressing oneself nonverbally is congruent with those cultures that look beyond words
for messages. Provides many experiments in working with clients who have cultural injunctions
against freely expressing feelings. Can help to overcome language barrier with bilingual clients.
Focus on bodily expressions is a subtle way to help clients recognize their conflicts.
Behavior
therapy
Focus on behavior, rather than on feelings, is compatible with many cultures. Strengths include a
collaborative relationship between counselor and client in working toward mutually agreed-upon goals,
continual assessment to determine if the techniques are suited to clients’ unique situations, assisting
clients in learning practical skills, an educational focus, and stress on self-management strategies.
Cognitive behavior
therapy
Focus is on a collaborative approach that offers clients opportunities to express their areas of
concern. The psychoeducational dimensions are often useful in exploring cultural conflicts and
teaching new behavior. The emphasis on thinking (as opposed to identifying and expressing feelings)
is likely to be acceptable to many clients. The focus on teaching and learning tends to avoid the
stigma of mental illness. Clients are likely to value the active and directive stance of the therapist.
Choice theory/
Reality therapy
Focus is on clients making their own evaluation of behavior (including how they respond to their
culture). Through personal assessment clients can determine the degree to which their needs and
wants are being satisfied. They can find a balance between retaining their own ethnic identity and
integrating some of the values and practices of the dominant society.
Feminist
therapy
Focus is on both individual change and social transformation. A key contribution is that both the
women’s movement and the multicultural movement have called attention to the negative impact
of discrimination and oppression for both women and men. Emphasizes the influence of expected
cultural roles and explores client’s satisfaction with and knowledge of these roles.
Postmodern
approaches
Focus is on the social and cultural context of behavior. Stories that are being authored in the therapy
office need to be anchored in the social world in which the client lives. Therapists do not make
assumptions about people and honor each client’s unique story and cultural background. Therapists
take an active role in challenging social and cultural injustices that lead to oppression of certain
groups. Therapy becomes a process of liberation from oppressive cultural values and enables clients
to become active agents of their destinies.
Family systems
therapy
Focus is on the family or community system. Many ethnic and cultural groups place value on the role
of the extended family. Many family therapies deal with extended family members and with support
systems. Networking is a part of the process, which is congruent with the values of many clients. There
is a greater chance for individual change if other family members are supportive. This approach offers
ways of working toward the health of the family unit and the welfare of each member.
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A N I N T E g R AT I V E P E R s P E C T I V E 447
TAbLe 15.8 Limitations in Multicultural Counseling
Psychoanalytic
therapy
Its focus on insight, intrapsychic dynamics, and long-term treatment is often not valued by clients
who prefer to learn coping skills for dealing with pressing daily concerns. Internal focus is often in
conflict with cultural values that stress an interpersonal and environmental focus.
Adlerian
therapy
This approach’s detailed interview about one’s family background can conflict with cultures that
have injunctions against disclosing family matters. Some clients may view the counselor as an
authority who will provide answers to problems, which conflicts with the egalitarian, person-to-
person spirit as a way to reduce social distance.
Existential
therapy
Values of individuality, freedom, autonomy, and self-realization often conflict with cultural values of
collectivism, respect for tradition, deference to authority, and interdependence. Some may be deterred
by the absence of specific techniques. Others will expect more focus on surviving in their world.
Person-centered
therapy
Some of the core values of this approach may not be congruent with the client’s culture. Lack of
counselor direction and structure are unacceptable for clients who are seeking help and immediate
answers from a knowledgeable professional.
Gestalt
therapy
Clients who have been culturally conditioned to be emotionally reserved may not embrace Gestalt
experiments. Some may not see how “being aware of present experiencing” will lead to solving their problems.
Behavior
therapy
Family members may not value clients’ newly acquired assertive style, so clients must be taught how
to cope with resistance by others. Counselors need to help clients assess the possible consequences
of making behavioral changes.
Cognitive behavior
therapy
Before too quickly attempting to change the beliefs and actions of clients, it is essential for the
therapist to understand and respect their world. Some clients may have serious reservations about
questioning their basic cultural values and beliefs. Clients could become dependent on the therapist
choosing appropriate ways to solve problems.
Choice theory/
Reality therapy
This approach stresses taking charge of one’s own life, yet some clients are more interested in
changing their external environment. Counselors need to appreciate the role of discrimination and
racism and help clients deal with social and political realities.
Feminist
therapy
This model has been criticized for its bias toward the values of White, middle-class, heterosexual
women, which are not applicable to many other groups of women nor to men. Therapists need to
assess with their clients the price of making significant personal change, which may result in isolation
from extended family as clients assume new roles and make life changes.
Postmodern
approaches
Some clients come to therapy wanting to talk about their problems and may be put off by the
insistence on talking about exceptions to their problems. Clients may view the therapist as an expert
and be reluctant to view themselves as experts. Certain clients may doubt the helpfulness of a
therapist who assumes a “not-knowing” position.
Family systems
therapy
Family therapy rests on value assumptions that are not congruent with the values of clients from
some cultures. Western concepts such as individuation, self-actualization, self-determination,
independence, and self-expression may be foreign to some clients. In some cultures, admitting
problems within the family is shameful. The value of “keeping problems within the family” may make
it difficult to explore conflicts openly.
and struggles, and to translate their insights into action programs by behaving in
new ways in day-to-day living. Table 15.9 outlines the contributions of various
approaches, and Table 15.10 describes some of the limitations of the various thera-
peutic approaches. These tables will help you identify elements that you may want
to incorporate in your own counseling perspective.
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448 C H A P T E R F I F T E E N
TAbLe 15.9 Contributions of the Approaches
Psychoanalytic
therapy
More than any other system, this approach has generated controversy as well as exploration
and has stimulated further thinking and development of therapy. It has provided a detailed and
comprehensive description of personality structure and functioning. It has brought into prominence
factors such as the unconscious as a determinant of behavior and the role of trauma during the first
six years of life. It has developed several techniques for tapping the unconscious and shed light on
the dynamics of transference and countertransference, resistance, anxiety, and the mechanisms of
ego defense.
Adlerian
therapy
A key contribution is the influence that Adlerian concepts have had on other systems and
the integration of these concepts into various contemporary therapies. This is one of the first
approaches to therapy that was humanistic, unified, holistic, and goal-oriented and that put an
emphasis on social and psychological factors.
Existential
therapy
Its major contribution is recognition of the need for a subjective approach based on a complete
view of the human condition. It calls attention to the need for a philosophical statement on what
it means to be a person. Stress on the I/Thou relationship lessens the chances of dehumanizing
therapy. It provides a perspective for understanding anxiety, guilt, freedom, death, isolation, and
commitment.
Person-centered
therapy
Clients take an active stance and assume responsibility for the direction of therapy. This unique
approach has been subjected to empirical testing, and as a result both theory and methods have
been modified. It is an open system. People without advanced training can benefit by translating
the therapeutic conditions to both their personal and professional lives. Basic concepts are
straightforward and easy to grasp and apply. It is a foundation for building a trusting relationship,
applicable to all therapies.
Gestalt
therapy
The emphasis on direct experiencing and doing rather than on merely talking about feelings
provides a perspective on growth and enhancement, not merely a treatment of disorders. It uses
clients’ behavior as the basis for making them aware of their inner creative potential. The approach
to dreams is a unique, creative tool to help clients discover basic conflicts. Therapy is viewed as
an existential encounter; it is process-oriented, not technique-oriented. It recognizes nonverbal
behavior as a key to understanding.
Behavior
therapy
Emphasis is on assessment and evaluation techniques, thus providing a basis for accountable
practice. Specific problems are identified, and clients are kept informed about progress toward
their goals. The approach has demonstrated effectiveness in many areas of human functioning.
The roles of the therapist as reinforcer, model, teacher, and consultant are explicit. The approach
has undergone extensive expansion, and research literature abounds. No longer is it a mechanistic
approach, for it now makes room for cognitive factors and encourages self-directed programs for
behavioral change.
Cognitive behavior
therapy
Major contributions include emphasis on a comprehensive therapeutic practice; numerous
cognitive, emotive, and behavioral techniques; an openness to incorporating techniques from
other approaches; and a methodology for challenging and changing faulty or negative thinking.
Most forms can be integrated into other mainstream therapies. REBT makes full use of action-
oriented homework, various psychoeducational methods, and keeping records of progress. CT is
a structured therapy that has a good track record for treating depression and anxiety in a short
time. Strengths-based CBT is a form of positive psychology that addresses the resources within
the client for change.
Choice theory/
Reality therapy
This is a positive approach with an action orientation that relies on simple and clear concepts
that are easily grasped in many helping professions. It can be used by teachers, nurses, ministers,
educators, social workers, and counselors. Due to the direct methods, it appeals to many clients who
are often seen as resistant to therapy. It is a short-term approach that can be applied to a diverse
population, and it has been a significant force in challenging the medical model of therapy.
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A N I N T E g R AT I V E P E R s P E C T I V E 449
Feminist
therapy
The feminist perspective is responsible for encouraging increasing numbers of women to question
gender stereotypes and to reject limited views of what a woman is expected to be. It is paving
the way for gender-sensitive practice and bringing attention to the gendered uses of power in
relationships. The unified feminist voice brought attention to the extent and implications of child
abuse, incest, rape, sexual harassment, and domestic violence. Feminist principles and interventions
can be incorporated in other therapy approaches.
Postmodern
approaches
The brevity of these approaches fit well with the limitations imposed by a managed care structure.
The emphasis on client strengths and competence appeals to clients who want to create solutions
and revise their life stories in a positive direction. Clients are not blamed for their problems but are
helped to understand how they might relate in more satisfying ways to such problems. A strength
of these approaches is the question format that invites clients to view themselves in new and more
effective ways.
Family systems
therapy
From a systemic perspective, neither the individual nor the family is blamed for a particular
dysfunction. The family is empowered through the process of identifying and exploring interactional
patterns. Working with an entire unit provides a new perspective on understanding and working
through both individual problems and relationship concerns. By exploring one’s family of origin,
there are increased opportunities to resolve other conflicts in systems outside of the family
TAbLe 15.10 Limitations of the Approaches
Psychoanalytic
therapy
Requires lengthy training for therapists and much time and expense for clients. The model stresses
biological and instinctual factors to the neglect of social, cultural, and interpersonal ones. Its methods
are less applicable for solving specific daily life problems of clients and may not be appropriate for
some ethnic and cultural groups. Many clients lack the degree of ego strength needed for regressive
and reconstructive therapy. It may be inappropriate for certain counseling settings.
Adlerian
therapy
Weak in terms of precision, testability, and empirical validity. Few attempts have been made to
validate the basic concepts by scientific methods. Tends to oversimplify some complex human
problems and is based heavily on common sense.
Existential
therapy
Many basic concepts are fuzzy and ill-defined, making its general framework abstract at times. Lacks
a systematic statement of principles and practices of therapy. Has limited applicability to lower
functioning and nonverbal clients and to clients in extreme crisis who need direction.
Person-centered
therapy
Possible danger from the therapist who remains passive and inactive, limiting responses to reflection.
Many clients feel a need for greater direction, more structure, and more techniques. Clients in crisis
may need more directive measures. Applied to individual counseling, some cultural groups will
expect more counselor activity.
Gestalt
therapy
Techniques lead to intense emotional expression; if these feelings are not explored and if cognitive
work is not done, clients are likely to be left unfinished and will not have a sense of integration
of their learning. Clients who have difficulty using imagination may not profit from certain
experiments.
Behavior
therapy
Major criticisms are that it may change behavior but not feelings; that it ignores the relational factors
in therapy; that it does not provide insight; that it ignores historical causes of present behavior; that
it involves control by the therapist; and that it is limited in its capacity to address certain aspects of
the human condition.
Cognitive behavior
therapy
Tends to play down emotions, does not focus on exploring the unconscious or underlying conflicts,
de-emphasizes the value of insight, and sometimes does not give enough weight to the client’s past.
CBT might be too structured for some clients.
(continued)
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450 C H A P T E R F I F T E E N
Evaluating the Effectiveness of Counseling and Therapy
Mental health providers must be accountable and be able to demonstrate
the efficacy of their services. In the era of managed care, it is essential for practi-
tioners to demonstrate the degree to which their interventions are both clinically
sound and cost-effective. Does therapy make a significant difference? Are people
substantially better after therapy than they were without it? Can therapy actually be
more harmful than helpful?
Evaluating how well psychotherapy works is far from simple. Therapeutic sys-
tems are applied by practitioners who have unique individual characteristics, and
clients themselves have much to do with therapeutic outcomes. For example, effects
resulting from unexpected and uncontrollable events in the client’s social environ-
ment can lessen the impact of gains made in psychotherapy. Moreover, practitioners
who adhere to the same approach are likely to use techniques in various ways and to
relate to clients in diverse fashions, functioning differently with different clients and
in different clinical settings.
How effective is psychotherapy? A meta-analysis of psychotherapy outcome lit-
erature conducted by Smith, Glass, and Miller (1980) concluded that psychotherapy
was highly effective and that all psychotherapeutic approaches worked about equally
well. Prochaska and Norcross (2014) note that controlled outcome research consis-
tently supports the effectiveness of psychotherapy. They point out that more than
5,000 individual studies and 500 meta-analyses have been conducted on the effec-
tiveness of psychotherapy; these studies demonstrate that well-developed therapy
interventions have meaningful, positive effects on the intended outcome variables.
In short, not only does psychotherapy work, but research demonstrates that therapy
is remarkably effective. Psychotherapy is an efficacious approach to helping people
who experience psychological distress improve their functioning (Miller et al., 2015).
LO7
Choice theory/
Reality therapy
Discounts the therapeutic value of exploration of the client’s past, dreams, the unconscious, early
childhood experiences, and transference. The approach is limited to less complex problems. It is a
problem-solving therapy that tends to discourage exploration of deeper emotional issues.
Feminist
therapy
A possible limitation is the potential for therapists to impose a new set of values on clients—such as
striving for equality, power in relationships, defining oneself, freedom to pursue a career outside the
home, and the right to an education. Therapists need to keep in mind that clients are their own best
experts, which means it is up to them to decide which values to live by.
Postmodern
approaches
There is little empirical validation of the effectiveness of therapy outcomes. Some critics contend
that these approaches endorse cheerleading and an overly positive perspective. Some are critical of
the stance taken by most postmodern therapists regarding assessment and diagnosis, and also react
negatively to the “not-knowing” stance of the therapist. Because some of the solution-focused and
narrative therapy techniques are relatively easy to learn, practitioners may use these interventions
in a mechanical way or implement these techniques without a sound rationale.
Family systems
therapy
Limitations include problems in being able to involve all the members of a family in the therapy.
Some family members may be resistant to changing the structure of the system. Therapists’ self-
knowledge and willingness to work on their own family-of-origin issues is crucial, for the potential
for countertransference is high. It is essential that the therapist be well trained, receive quality
supervision, and be competent in assessing and treating individuals in a family context.
TAbLe 15.10 Limitations of the Approaches (continued)
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A N I N T E g R AT I V E P E R s P E C T I V E 451
A summary of the research data shows little or no difference in outcome between
specific therapeutic approaches (Miller et al., 2015). Lambert’s (2011) review of psy-
chotherapy research makes it clear that the similarities rather than the differences
among models account for the effectiveness of psychotherapy. Interpersonal, social,
and affective factors common across therapeutic orientations are the primary deter-
minants of effectiveness (Elkins, 2016).
Although it is clear that therapy works, there are no simple explanations of how
it works. Research indicates that a variety of treatments are equally effective—when
administered by therapists who believe in them and when they are accepted by the
client. Wampold (2010) concludes that “there is little evidence that the specific
ingredients of any treatment are responsible for the benefits of therapy” (p. 71).
The various therapy approaches and techniques work equally well because they
share the most important ingredient accounting for change—the client. Data point
to the conclusion that the engine of change is the client (Bohart & Tallman, 2010;
Bohart & Wade, 2013), and we can most productively direct our efforts toward ways
of employing the client in the process of change.
Feedback-Informed Treatment
Listening to client feedback about the therapy process is of the utmost impor-
tance. Feedback-informed treatment (Fit) is designed to evaluate and to improve
the quality and effectiveness of counseling services. FIT is an evidence-based
practice that monitors client change and identifies modifications needed to enhance
the therapeutic endeavor (Miller et al., 2015). FIT involves consistently obtaining
feedback from clients regarding the therapeutic relationship and their clinical prog-
ress, which is then used to tailor therapy to their unique needs. If therapists learn to
listen to clients’ feedback throughout the therapeutic process, clients can become
full and equal participants in all aspects of their therapy (Miller et al., 2015).
Monitoring outcome and adjusting accordingly on the basis of feedback from
the client must become routine practice. The client’s theory of change can be used as
a basis for determining which approach, by whom, can be most effective for this per-
son, with his or her specific problem, under this particular set of circumstances. This
approach to practice requires continuous active client input, which is the most sig-
nificant predictor of change in therapy (Hubble, Duncan, Miller, & Wampold, 2010).
Duncan (2014) believes that systematic client feedback should be integrated
into all psychotherapeutic approaches because of its proven effectiveness in help-
ing clients monitor and improve their therapy experience. Scott Miller and his
associates at the International Center for Clinical Excellence (ICCE) developed two
4-item instruments to measure client progress and to rate the quality of the thera-
peutic relationship. These rating instruments are brief, well-validated, client-rated
scales. The Outcome rating scale (Ors) assesses the client’s therapeutic prog-
ress through ratings of a client’s personal experience of well-being in his or her
individual, interpersonal, and social functioning. The session rating scale (srs)
measures a client’s perception of the quality of the therapeutic relationship, which
includes the relational bond with the therapist, the perceived collaboration around
specific tasks in therapy, and agreement on goals, methods, and client preferences
(Miller et al., 2015).
LO8
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452 C H A P T E R F I F T E E N
Feedback from clients regarding the therapeutic alliance and outcomes increases
the effect of treatment, cuts dropout rates in half, and decreases the risk of deteriora-
tion (Miller, 2011). Using client feedback, therapists can adjust and accommodate
to maximize beneficial outcomes for clients. In essence, Duncan, Miller, and Sparks
(2004) are arguing for practice-based evidence rather than evidence-based practice:
“Becoming outcome informed not only amplifies the client’s voice but offers the
most viable, research-tested method to improve clinical effectiveness” (p. 16). Cli-
ent strengths and perceptions are the foundation of therapy work. Systematic and
consistent assessment of the client’s perceptions of progress allows the therapist
to customize the therapy to the individual needs and characteristics of each client.
Ongoing client feedback provides practitioners with a simple, practical, and mean-
ingful method for documenting the usefulness of treatment.
In this section, I describe how I would integrate con-cepts and techniques from the 11 theoretical per-
spectives in counseling Stan on the levels of thinking,
feeling, and doing. I indicate what aspects from the vari-
ous theories I would draw on in working with Stan at
the various stages of his therapy. As you read the Ques-
tions for Reflection at the end of this section, think
about how you would work with Stan from your own
integrative perspective.
clarifying the therapeutic relationship
In establishing the therapeutic relationship, I am in-
fluenced by the person-centered, existential, Gestalt,
feminist, postmodern, and Adlerian approaches. I ask
myself these questions: “To what degree am I able to
listen to and hear Stan in a nonjudgmental way? Am
I able to respect and care for him? Do I have the ca-
pacity to enter his subjective world without losing my
own identity? Am I able to share with him my own
thoughts and reactions as they pertain to our relation-
ship?” I invite Stan’s questions about this therapeutic
relationship. One goal is to demystify the therapy pro-
cess; another is to get some focus for the direction of
our sessions by developing clear goals for the therapy.
clarifying the goals of therapy
With respect to setting goals, precision and clarity are
essential. Once we have identified some goals, Stan can
begin to observe and measure his own behavior, both in
the sessions and in his daily life. This self-monitoring is
a vital step in any effort to bring about change. I will be
asking for Stan’s feedback throughout the therapeutic
process and will use his feedback as a basis for making
modifications in our therapeutic alliance.
Throughout our time together, I ask Stan to decide
time and again what he wants from his therapy and to
assess the degree to which our work together is helping
him meet his goals. It is important that Stan provide
the direction in which he wants to travel on his journey.
Once I have a clear sense of the specific ways Stan wants
to change how he is thinking, feeling, and acting, I am
likely to take an active role in co-creating experiments
with Stan that he can do both in the therapy sessions
and on his own away from our sessions.
Working With stan’s Past, Present,
and Future
Dealing With the Past In my integrative approach,
I tend to give weight to understanding, exploring, and
working with Stan’s early history and to connect his
past with what he is doing today. My view is that themes
running through our life can become evident if we come
to terms with significant experiences in our childhood. I
favor the Gestalt approach of asking Stan to bring into
the here and now those people in his life with whom
he feels unfinished. A variety of role-playing techniques
in which Stan addresses significant others through
symbolic work in our sessions will bring Stan’s past
intensely to life in the present moment of our sessions.
An Integrative Approach Applied to the Case of Stan
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A N I N T E g R AT I V E P E R s P E C T I V E 453
Dealing With the Present Being interested in
Stan’s past does not mean that we get lost in history
or that we dwell on reliving traumatic situations. By
paying attention to what is going on in the here and
now during the counseling session, I get significant
clues about what is unfinished from Stan’s past.
He and I can direct attention to his immediate
feelings as well as to his thoughts and actions. It
seems essential to me that we work with all three
dimensions—what he is thinking, what he is actually
doing, and how his thoughts and behaviors affect
his feeling states.
Dealing With the Future If Stan decides that his
present behavior is not getting him what he wants,
he is in a good position to think ahead about the
changes he would like to make and what he can do
now to actualize his aspirations. The present-oriented
behavioral focus of reality therapy is a good reference
point for getting Stan to dream about what he would
like to say about his life five years hence. Connecting
present behavior with future plans is an excellent
way to help Stan formulate a concrete plan of action,
which can give him a way to create his future.
identifying and exploring Feelings
The authenticity of my relationship with Stan encour-
ages him to begin to identify and share with me a range
of feelings. Our open and trusting relationship is not
sufficient to change Stan’s personality and behavior,
however, and I continue to use my knowledge, skills,
and experiences to help Stan clarify his own thoughts.
Stan is the best expert on his own life, and I assist him
in coming to value the ways in which he is the expert
in the therapeutic endeavor as well.
I draw heavily on Gestalt experiments to help Stan
express and explore his feelings. Eventually, I ask him
to avoid merely talking about situations and about
feelings. Rather, I encourage him to bring whatever
reactions he is having into the present. For instance,
if I notice tears in his eyes, I may direct him to “be his
tears now.” By putting words to his tears, he avoids ab-
stract intellectualization about all the reasons he is sad
or tense. Before he can change his feelings, Stan must
allow himself to fully experience them. The experiential
therapies provide valuable tools for guiding him to the
expression of his feelings.
the thinking Dimension in therapy
Once Stan has experienced some intense feelings and
perhaps released pent-up feelings, some cognitive
work is essential. To bring in this cognitive dimension,
I focus Stan’s attention on messages he incorporated
as a child and on the decisions he made. I get him to
think about the reason he made certain early deci-
sions. Finally, I challenge Stan to look at these deci-
sions about life, about himself, and about others and
to make necessary revisions that can lead him to creat-
ing a life of his own choosing.
The cognitive behavioral therapies have a range of
cognitive techniques that can help Stan recognize con-
nections between his cognitions and his behaviors. Over
a number of sessions we work on specific beliefs. My
role is to promote corrective experiences that will lead
to changes in his thinking. Eventually, our goal is some
cognitive restructuring work by which Stan can learn
new ways to think, new things to tell himself, and new
assumptions about life. I have given Stan a number of
homework assignments aimed at helping him identify a
range of feelings and thoughts that may be problematic
for him. This provides a basis for change in his behavior.
Doing: another essential component
of therapy
Feeling and thinking are not a complete therapy
process. Doing is a way of bringing these feelings and
thoughts together by applying them to real-life situ-
ations in various action programs. I ask Stan to think
of as many ways as possible of actually bringing into
his daily living the new learning he is acquiring in our
sessions. Homework assignments (preferably ones
that Stan gives himself) are an excellent way for Stan
to become an active agent in his therapy. He must do
something himself for change to occur. The degree to
which he will change is directly proportional to his
willingness to experiment. Thus, each week we discuss
his progress toward meeting his goals, and we review
how well he is completing his assignments, as well as
how his action plan is working.
Moving toward termination of therapy
Termination of therapy is as important as the initial
phase, for now the key task is to put into practice what
he has learned in the sessions by applying new skills
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454 C H A P T E R F I F T E E N
and attitudes to daily social situations without profes-
sional assistance. When Stan brings up a desire to “go
it alone,” we talk about his readiness to end therapy
and his reasons for thinking about termination. I also
share with him my perceptions of the directions I have
seen him take. This is a good time to talk about where
he can go from here. We spend time developing an ac-
tion plan and talking about how he can best maintain
his new learning.
In a behavioral spirit, evaluating the process and
outcomes of therapy seems essential. This evaluation
can take the form of devoting some time to discuss-
ing Stan’s specific changes in therapy. A few questions
for focus are: “What stands out the most for you,
Stan? What did you learn that you consider the most
valuable? How did you learn these lessons? What can
you do now to keep practicing new behaviors? What
will you do if you experience a setback?” We explore
potential difficulties he expects to face when he no
longer comes to weekly counseling sessions. At this
point, I introduce some relapse prevention strategies
to help Stan cope constructively with future prob-
lems. By addressing potential problems and stum-
bling blocks that he might have to deal with, Stan
is less likely to become discouraged if he experiences
any setbacks. If any relapses do occur, we talk about
seeing these as “learning opportunities” rather than
as signs that he has failed. I let Stan know that his
termination of formal therapy does not mean that he
cannot return for a visit or session when he considers
it appropriate.
commentary on the thinking, Feeling,
and Doing Perspective
Although the steps I described with Stan may appear
relatively structured and even simple, actually work-
ing with clients is more complex and less predictable.
If you are practicing from an integrative perspec-
tive, it would be a mistake to assume that it is best
to always begin working with what clients are think-
ing (or feeling or doing). Effective counseling begins
where the client is, not where a theory indicates a cli-
ent should be.
In summary, depending on what clients need at
the moment, I may focus initially on what they are
thinking and how this is affecting them, or I may focus
on how they feel, or I may choose to direct them to pay
attention to what they are doing. If Stan can change
his thoughts, I believe he is likely to change some of
his behaviors and his feelings. If he changes his feel-
ings, he might well begin to think and act differently.
If he changes certain behaviors, he may begin thinking
and feeling differently. Because these facets of human
experience are interrelated, one route generally leads
to the other dimensions.
A person-centered focus respects the wisdom
within the client and uses it as a lead for where to go
next. As counselors, a mistake we can make is getting
too far ahead of our clients by thinking, “What should
I do next?” By staying with our clients and asking
them what they want, they will tell us which direction
to take either directly or indirectly. We can learn to pay
attention to our own reactions to our clients and to
our own energy. By doing so we can engage in a thera-
peutic connection that is helpful for both parties in
the relationship.
Questions for Reflection
�� What themes in Stan’s life do you find most sig-
nificant, and how might you draw on these themes
during the initial phase of counseling?
�� What specific concepts from the various theoreti-
cal orientations would you be most inclined to
utilize in your work with Stan?
�� Identify some key techniques from the various
therapies that you are most likely to employ in
your therapy with Stan.
�� How would you develop experiments for Stan
to carry out both inside and outside the therapy
sessions?
�� Knowing what you do about Stan, what do you
imagine it would be like to be his therapist? What
problems, if any, might you expect to encounter in
your counseling relationship with him?
Visit CengageBrain.com or watch the DVD for the
video program on Theory and Practice of Counseling
and Psychotherapy: The Case of Stan and Lecturettes,
session 13 (an integrative approach), for a dem-
onstration of my approach to counseling stan
from this perspective. This session deals with
termination and takes an integrative view of
stan’s work.
63727_ch15_rev02.indd 454 31/08/15 1:20 PM
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A N I N T E g R AT I V E P E R s P E C T I V E 455
T here are multiple pathways to health and well-being, and I believe Gwen can benefit from a va-
riety of counseling theories and holistic practices. The
integrative approach embraces an attitude that affirms
the intrinsic value of each individual. It is a unifying
approach that attends to the person at the affective,
behavioral, cognitive, and physiological levels of func-
tioning. It also addresses the spiritual dimension of a
client’s life.
As an integrative therapist and a woman of color,
I am willing to share my experiences with Gwen when
it is therapeutically appropriate. I want Gwen to know
that I respect her life experiences, struggles, strengths,
unique qualities, and personal reality. I see Gwen as an
intelligent African American woman with great depth
and wisdom. Utilizing an integrative approach with
Gwen allows me to take into account the many views
of the change process that are available to assist her at
this time in her life.
In my initial interview with Gwen, I let her know
that I am not a purist in my approach to therapy and
that I will draw from different counseling theories to cre-
ate a treatment approach that is tailored to her needs. I
begin establishing a therapeutic alliance with Gwen by
drawing heavily from a client-centered orientation It is
important for me to extend unconditional positive re-
gard in the midst of acknowledging the suffering and
anxiety Gwen is experiencing in her day-to-day life. I
want Gwen to know that she is the expert on her life and
that she is in charge of our work together. I will intro-
duce ideas and techniques, and I let Gwen know that she
is free to say what does not work for her in our sessions.
When Gwen and I began our therapeutic journey
together, I was very interested in learning about her
family history. I encouraged Gwen to create a geno-
gram that depicted three generations and indicated
educational levels, health issues, relationship patterns,
and religious orientation. This approach was borrowed
from family therapy and assisted us in seeing family
patterns that have given her strength and support (her
spirituality), as well as patterns that have caused chal-
lenges for her (taking on family members’ problems).
Through exploring her family history, Gwen begins to
slowly recognize she has taken on characteristics that
don’t necessarily belong to her. Generational trans-
mission—passing down traits, habits, and values from
one generation to the next—has predisposed Gwen to
be a rescuer like many of her female relatives. She ex-
plores some of the old automatic negative thoughts
that were passed on from other generations that keep
her feeling overwhelmed. One of Gwen’s faulty beliefs
is that “If I don’t do it, no one else will.” This particular
cognitive distortion keeps her is a spiral of doing ev-
erything without reaching out to others for assistance
or support. Her belief that no one else can assist her
has caused fatigue and frustration. Through cognitive
behavior therapy, Gwen becomes more aware of the
thoughts she is thinking and how they affect how she
feels about herself.
Using an integrative format allows me to incorpo-
rate everything Gwen brings to therapy as a route to her
own healing process. Gwen shared with me early in our
sessions that her relationship with God was a source
of great strength in her life. I acknowledge and respect
Gwen’s spiritual values, and I pay attention to how her
spirituality can be a significant part of her treatment
and healing. Spirituality became a central part of our
therapy sessions because Gwen made it clear that her
spiritual beliefs were a vital resource for her.
I asked Gwen to talk about what was most helpful
about the way she worshiped. Gwen replied, “I enjoy
reading the scriptures. It helps me to see that I am not
alone and that my problems are not new. There are
messages that I can reflect on in scripture. Reading the
Bible gives me comfort in my spirit.” We explore the
existential questions around the meaning in life and
talk about suffering, anxiety, and death. Gwen strug-
gles with fears for her son’s life, and she feels great sad-
ness as her mother’s health declines. Gwen’s spiritual-
ity is becoming her anchor and support as she wrestles
with these realities of life.
Bringing in the dimension of spirituality recon-
nects Gwen to a daily practice of reading scripture in
the morning and listening to praise music on the way
An Integrative Approach Applied to the Case of Gwen*
*Dr. Kellie Kirksey writes about her ways of thinking and practicing from an integrative perspective and applying this model to Gwen.
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456 C H A P T E R F I F T E E N
to the office. Gwen notices that her mood is not as
negative when she engages in her daily spiritual prac-
tice. She hadn’t realized that she had stopped engag-
ing in activities that kept her focused and uplifted. The
stress of taking care of her mother and juggling work
and family life created an imbalance that perpetuated
faulty cognitions and behaviors.
In our early sessions Gwen engaged in automatic
negative thinking and made statements such as “I am
never going to feel healthy again.” “My children never
want to spend time with me.” “I will always feel iso-
lated.” Examining Gwen’s cognitive distortions and
assisting her in noticing and challenging them helped
her to become increasingly aware of how these thought
patterns cause her distress.
I introduced Gwen to a simple 5-minute medita-
tion practice aimed at both calming her mind of anxious
thoughts and increasing her ability to focus. I suggested
to Gwen that during these brief meditations she could
notice her thoughts without judgment. This simple
mindfulness practice is likely to have a cumulative im-
pact on her ability to relax and gain more inner resil-
ience. With continued practice, Gwen discovers that she
is not simply her thoughts, that she can be the observer
of those thoughts, and that she can watch them flow by
rather than letting them control her behavior and mood.
I typically begin and end each session with a brief
assessment by Gwen about the session. I depend on
regular feedback to make the process truly collabora-
tive and to ensure that Gwen’s therapeutic needs are
being met. My first question for Gwen is always: “How
would you like to best use the time we have together?”
My job is to be fully present so that I can effectively
integrate therapeutic approaches that will assist Gwen
on her journey of transformation as she returns to a
state of optimal functioning and balance.
I make no assumptions and ask Gwen if she is will-
ing to work with what naturally arises as the therapy
progresses. If she does not give an affirmative answer,
then our direction of therapy needs to be modified. I
explain that my techniques are aimed at meeting Gw-
en’s goals and healing her needs. This statement seems
to increase Gwen’s comfort level, and she is more will-
ing to try new ways of being in a session.
To decrease Gwen’s symptoms of depression and
anxiety, I introduce her to a process I call “transfor-
mative movement and reflection.” I teach Gwen a vari-
ety of techniques, range from subtle to dynamic, that
come from global healing practices such as yoga, tai
chi, drumming, and yogic pranayama, to mention a
few. These activities increase mindfulness and present
moment awareness and help Gwen release tension and
stress from her body and mind. The movement prac-
tices also assist in healthy emotional expression. Gwen
is not very interested in drumming, but listening to
music and moving is relaxing for her while in session
and at home. Gwen begins to see that she has resourc-
es and tools that she can use in moments of stress in
her daily life. My goal is to introduce Gwen to multiple
tools to heal on the levels of mind, body, and spirit. I
am sensitive to Gwen’s personal goals from the mo-
ment she walks into my office, and I remain open to
the possibilities that lie ahead of us until the very end.
Questions for Reflection
�� What ideas and techniques shared in this piece
belong to each theoretical approach?
�� How comfortable are you in introducing nontradi-
tional therapeutic techniques?
�� Based on who you are, what theories seem to be the
most natural for you to utilize from an integrative
theoretical approach when working with Gwen?
Summary
Creating an integrative stance is truly a challenge. Therapists cannot simply pick
bits and pieces from theories in a random and fragmented manner. In forming
an integrated perspective, it is important to ask: Which theories provide a basis
for understanding the cognitive dimensions? What about the feeling aspects? And
how about the behavioral dimension? Most of the 11 therapeutic orientations
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A N I N T E g R AT I V E P E R s P E C T I V E 457
discussed here focus primarily on one of these dimensions of human experience.
Although the other dimensions are not necessarily ignored, they are often given
short shrift.
Developing an integrated theoretical perspective requires an accurate, in-depth
knowledge of the various theories. Without such knowledge, you cannot formulate
a true synthesis. Simply put, you cannot integrate what you do not know (Nor-
cross & Beutler, 2014). A central message of this book has been to remain open to
each theory, to do further reading, and to reflect on how the key concepts of each
approach fit your personality. Building your personalized orientation to counseling,
which is based on what you consider to be the best features of several theories, is a
long-term venture.
In addition to considering your own personality, think about what concepts
and techniques work best with a range of clients. It requires knowledge, skill, art,
and experience to be able to determine what techniques are suitable for particular
problems. It is also an art to know when and how to use a particular therapeu-
tic intervention. Although reflecting on your personal preferences is important, I
hope that you balance your preferences with evidence from the research studies.
Developing a personal approach to counseling practice does not imply that any-
thing goes. Indeed, in this era of managed care and evidence-based practice, your
personal preferences will not likely be the sole determinant of your psychotherapy
practice. In counseling clients with certain clinical problems (such as depression
and generalized anxiety), specific techniques have demonstrated their effective-
ness. For instance, behavior therapy, cognitive behavior therapy, cognitive therapy,
mindfulness-based cognitive therapy, and short-term psychodynamic therapy
have repeatedly proved successful in treating depression. Your use of techniques
must be grounded on solid theoretical constructs. Ethical practice implies that
you employ efficacious procedures in dealing with clients and their problems, and
that you are able to provide a theoretical rationale for the interventions you make
in your clinical work.
This is a good time to review what you have learned about counseling theory
and practice. Identify a particular theory that you might adopt as a foundation
for establishing your counseling perspective. Consider from which therapies you
would be most inclined to draw (1) underlying assumptions, (2) major concepts,
(3) therapeutic goals, (4) therapeutic relationship, and (5) techniques and pro-
cedures. Also, consider the major applications of each of the therapies as well
as their basic limitations and major contributions. The tables presented in this
chapter are designed to assist you in conceptualizing your view of the counseling
process.
Concluding Comments
At the beginning of the introductory course in counseling, my students typically
express two reactions: “How will I ever be able to learn all these theories, and how
can I see the differences among them?” and “How can I make sense out of all
this information?” By the end of the course, these students are often surprised by
how much work they have done and by how much they have learned. Although
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458 C H A P T E R F I F T E E N
an introductory survey course will not turn you into accomplished counselors, it
generally provides the basis for selecting from among the many models to which
you are exposed.
At this point you may be able to begin putting the theories together in some
meaningful way for yourself. This book will have served its central purpose if it has
encouraged you to read further and to expand your knowledge of the theories that
most caught your interest. I hope you have seen something of value that you can use
from each of the approaches described. You will not be in a position to conceptual-
ize a completely developed integrative perspective after your first course in coun-
seling theory, but you now have the tools to begin the process of integration. With
additional study and practical experience, you will be able to expand and refine your
emerging personal philosophy of counseling.
Finally, the book will have been put to good use if it has stimulated you to
think about the ways in which your philosophy of life, your values, your life
experiences, and the person you are becoming are vitally related to the caliber of
counselor you can become and to the impact you can have on those who estab-
lish a relationship with you personally and professionally. This book and your
course may have raised questions for you regarding your decision to become a
counselor. Seek out at least one of your professors and explore any questions
you may have.
Self-Reflection and Discussion Questions
1. What are the four major approaches to psychotherapy integration?
How can these routes to integration be useful for you in designing your
perspective on counseling?
2. In feedback-informed treatment, clients provide reactions to their expe-
rience of the session and to the therapist. How open do you imagine
you would be to hearing honest feedback from your clients about you
as a therapist and about the interventions you are making? Do you
see yourself as being able to engage in a discussion with your clients
regarding both their positive and negative reactions to a session?
3. In developing your integrative approach to counseling, what factors
would you most consider?
4. What importance do you place on research that seeks to identify what
makes psychotherapy work?
5. If you had to select one theory that would serve as your primary theory,
which theory would you select and why?
Where to Go From Here
In the DVD for Integrative Counseling: The Case of Ruth and Lecturettes (Session 9, “An
Integrative Perspective”) you will view my ways of working with Ruth by drawing
on techniques from various theoretical models. I demonstrate how the foundation
of my integrative approach rests on existential therapy. In this session I am drawing
heavily from principles of the action-oriented therapies.
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A N I N T E g R AT I V E P E R s P E C T I V E 459
Other Resources
The International Center for Clinical Excellence (ICCE) is a worldwide web-based
community of practitioners, health care managers, administrators, educators, poli-
cymakers, and researchers dedicated to promoting excellence in behavioral health
care services. This online community facilitates sharing best practices and innova-
tive ideas specifically designed to improve behavioral health care practice and enable
practitioners and managers to achieve their personal best as helping professionals.
The ORS and the SRS rating scales described in the text can be downloaded for free
at the website.
The ICCE manuals on feedback-informed treatment (FIT) consist of a series of
six guides covering the most important information for practitioners and agencies
implementing FIT as a part of routine care. The manuals cover the following con-
tent areas:
Manual 1. What Works in Therapy: A Primer
Manual 2. Feedback-Informed Clinical Work: The Basics
Manual 3. Feedback-Informed Supervision
Manual 4. Documenting Change: A Primer on Measurement, Analysis,
and Reporting
Manual 5. Feedback-Informed Clinical Work: Specific Populations and
Service Settings
Manual 6. Implementing Feedback-Informed Work in Agencies and Sys-
tems of Care
The goal for the series is to provide practitioners with a thorough grounding in
the knowledge and skills associated with outstanding clinical performance. These
manuals are a useful resource for clinicians who want to learn to practice FIT. For
more information about ICCE and the resources available, contact:
The International Center for Clinical Excellence
www.centerforclinicalexcellence.com
Scott D. Miller’s website has additional information on workshops on clinical
excellence:
Scott D. Miller
www.scottdmiller.com
Recommended Supplementary Readings
Psychotherapy Integration (Stricker, 2010) is a concise
presentation that deals with the theory, therapeu-
tic process, evaluation, and future developments of
integrative approaches.
The Human Element of Psychotherapy: A Nonmedi-
cal Model of Emotional Healing (Elkins, 2016) devel-
ops the thesis that psychotherapy is decidedly a
relational, not a medical, endeavor. This book sum-
marizes research supporting the notion that the
quality of the interpersonal connection between cli-
ent and therapist is what determines effectiveness,
not the therapist’s theory or techniques.
Handbook of Psychotherapy Integration (Norcross
& Goldfried, 2005) is an excellent resource for
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460 C H A P T E R F I F T E E N
conceptual and historical perspectives on therapy
integration. This edited volume gives a comprehen-
sive overview of the major current approaches, such
as theoretical integration and technical eclecticism.
The Sage Encyclopedia of Theory in Counseling and
Psychotherapy (Neukrug, 2015) is an comprehen-
sive collection of short articles on the spectrum of
approaches and techniques for counseling.
The Art of Integrative Counseling (Corey, 2013a) is
designed to assist students in developing their own
integrative approach to counseling. This book is
complemented by the DVD for Integrative Counseling:
The Case of Ruth and Lecturettes (Corey, 2013c).
Case Approach to Counseling and Psychotherapy (Corey,
2013b) illustrates each of the 11 contemporary
theories by applying them to the single case of
Ruth. I also demonstrate my integrative approach
in counseling Ruth in the final chapter. This book
also is designed to fit well with the DVD for Inte-
grative Counseling: The Case of Ruth and Lecturettes
(Corey, 2013c).
Integrating Spirituality and Religion into Counseling: A
Guide to Competent Practice (Cashwell & Young, 2011)
offers a concrete perspective on how to provide
counseling in an ethical manner, consistent with a
client’s spiritual beliefs and practices. The authors
help practitioners develop a respectful stance that
honors the client’s worldview and works within this
framework in a collaborative fashion to achieve the
client’s goals.
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Part 1
Basic Issues in Counseling Practice
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*Corey, G., Corey, M., & Haynes, R.
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Psychoanalytic Therapy
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A N I N T E G R AT I V E P E R S P E C T I V E 481 Name Index
Adams, M., 137, 140, 145–146, 148
Adler, A., 6, 78, 96, 98, 101–103, 271, 406
Al-Rashidi, B., 328–329
American Counseling Association (ACA),
23, 49
American Counseling Association Code
of Ethics, 42, 49, 52
American Psychiatric Association, 46,
102, 405
American Psychological Association,
340
Andersen, T., 410
Anderson, C., 407, 416
Anderson, H., 369–370, 376, 410
Ansbacher, H., 98–103, 114, 125
Ansbacher, R., 99–103, 114
Antony, M., 233–234, 239, 248, 251
APA Presidential Task Force on
Evidence-Based Practice, 48
Arciniega, G., 119–120
Arkowitz, H., 182
Arlow, J., 67–70, 91–92
Arnkoff, D., 431
Arredondo, P., 26
Asnaani, A., 281, 287, 305
Austin, S., 174
Axelsson, L., 199–200, 210–211
Baldwin, M., 411
Bandura, A., 7, 232–235
Banmen, J., 408
Barber, J., 69
Barber, P., 225
Barnett, J., 44, 46
Bateson, G., 377, 386
Batten, S., 256
Beck, A., 7, 270, 280–282, 284–288
Beck, J., 7, 270, 280–281, 286–287
Becvar, D., 404
Becvar, R., 404
Beisser, A., 201
Bell, A., 428
Bemak, F., 44–45
Berg, I., 7, 369–370, 374, 377–379, 397
Bertram, B., 42–43
Bertolino, B., 369, 387, 391, 397
Beutler, L., 48, 428–430, 434, 442
Binswanger, L., 135
Bisono, A., 436
Bitter, J., 97, 100, 102, 108–109, 112,
114–116, 118–119, 125–126, 346,
348, 406, 408–410, 414, 423
Black, M., 82
Blau, S., 272
Blau, W., 73
Bohart, A., 165, 171, 173, 176–177,
185, 451
Borden, A., 381
Boscolo, L., 424
Boss, M., 135
Bowen, M., 7, 407
Bowman, C., 214
Bozarth, J., 165–167, 171, 177–178
Brabeck, K., 346, 348, 362
Brabeck, M., 346, 348, 362
Bracke, P., 158
Breshgold, E., 213, 224
Breunlin, D., 409, 415
Brickell, J., 322, 324, 328–329, 333
Brodsky, A., 52
Bromley, D., 48
Brooks, J., 185
Brown, J., 199, 201, 210
Brown, L., 7, 339, 341, 344, 348–349,
363, 369
Brown, S., 26
Brownell, P., 211–212, 225
Bubenzer, D., 375, 409
Buber, M., 135, 149
Bugental, J., 133–134, 136–137, 147, 149,
151, 158
Burns, A., 48
Butler, A., 286
Byars-Winston, A., 340, 345
Cain, D., 164–165, 169, 173–177,
185–186, 190–191
Cairrochi, J., 256
Callaghan, G., 236, 264
Callanan, P., 38, 40, 42–43
Cannon, K., 343
Carlson, J.D., 19–20, 96–97, 100–103,
106, 109, 114, 116, 119, 121,
125–126, 409
Carlson, J.M., 121
Carmichael, A., 405
Carter, B., 407
Cashwell, C., 436–437
Castaldo, J., 287
Cavasos, L., 185
Cecchin, F., 424
Chambless, D., 287
Chang, R., 258–259
Christensen, O., 108–109, 112, 406
Chung, R., 44–45
Clark, A., 102, 106, 111–112, 175
Clark, D., 288
Clarkin, J., 82
Clayton, X., 287
Clemmer, F., 102
Cole, E., 338–339
Cole, L., 126, 346
Comas-Diaz, L., 435
Combs, G., 382, 384, 386, 397
Comstock, D., 343
Conyne, R., 205, 214, 218–219
Cooper, M., 137, 159
Corbett, G., 182–183
Corey, C., 38, 40, 42–43
Corey, G., 13, 24, 34, 38–40, 42–43, 47,
49–50, 73, 77, 113, 119, 146, 150,
153, 177, 180, 211, 220, 239, 243,
250, 258, 275–276, 279, 289, 327,
346, 362, 380–381, 389, 429, 431
Corey, M., 38–40, 42–43, 146, 219
Cormier, S., 238, 243, 245, 250
Craske, M., 245–246
Crawford, T., 276
Crethar, H., 340, 354
Crocket, K., 382, 385
Cukrowicz, K., 48
Cummins, A., 287
Curtis, R., 69, 71, 73–75
Dailey, S., 47
Dattilio, F., 48, 158, 232, 235, 285–289,
307
Dean, L., 182
Deegear, J., 48
DeJong, P., 369–370, 374, 377–379, 397
Delaney, H., 436
de Shazer, S., 7, 369, 371–374, 376–378,
397
Deurzen, E., van, 133, 137, 140, 144–146,
148–153, 158–159
Dienes, K., 270, 286
DiGiuseppe, R., 263–264, 285, 304
Dimidjian, S., 253
Dinkmeyer, D., 100, 108, 116
DiPietro, R., 106, 111, 125
Disque, J., 116
Donovan, D., 296
Doolin, E., 175
Dreeben, S., 253–254
Dreikurs, R., 6, 98, 103, 105, 108–109,
118, 406, 414–415
Drewery, W., 386
Driscoll, K., 48
Dudley, R., 290
Duffey, T., 353
Duncan, B., 18, 178, 192, 397, 430, 442,
451–452
481
63727_Name Index_rev01.indd 481 21/09/15 3:52 PM
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
482 N A m E I N d E x
Edwards, J., 48
Eldridge, N., 343
Elkins, D., 18–19, 149, 157, 164–167,
171, 190, 192, 430–431, 442, 451
Elliott, R., 176
Ellis, A., 7, 270–279, 304, 306
Ellis, D., 271–279, 304, 306–307
Emery, G., 282
Englar-Carlson, M., 106, 114, 119,
126, 353
Enns, C.Z., 7, 92, 338–341, 344–345,
348–349, 351, 353–354, 362
Epp, L., 153
Epstein, N., 287
Epston, D., 7, 369, 372, 381–382, 384,
387–389, 410
Eriksen, K., 348, 353
Erikson, E., 59, 64–66
Espin, O., 7, 338–339
Evans, K., 340, 344–346, 348–350,
352–353
Evans, M., 353
Evans, T., 114
Fang, A., 281, 287, 305
Farber, B., 175
Farha, B., 143
Fassinger, R., 339–340, 352
Feder, B., 220
Ferguson, K., 243
Fernbacher, S., 220
Fishman, D., 252
Fishman, H., 424
Fitzpatrick, S., 252–253
Follette, V., 250, 256
Follette, W., 236, 264
Forman, E., 250–251, 256
Frame, M., 436–437
Frankl, V., 6, 130, 140, 144
Franklin, C., 371
Freedman, J., 381–382, 384, 386, 397
Freeman, A., 270, 281, 285–287,
303–304, 307
Freeman, S., 303–304
Freiberg, H., 167
Freud, S., 6, 58–61, 64–66, 77–78
Frew, J., 202–203, 210–211, 213–214, 220
Fulton, P., 251, 256
Gamori, M., 408
Garcia-Preto, N., 407
Gavey, N., 348
Gelder, M., 288
Geller, J., 21–22
Gelso, C., 71–72
George, E., 375–376, 379
Gerber, J., 408
Gerdes, P., 322
Gergen, K., 368
Germer, C., 251, 254–256
Gerson, R., 407
Gill, C., 47
Gilligan, C., 339, 341–342
Gingerich, W., 371
Gladding, S., 409–410
Glass, C., 431
Glass, G., 450
Glasser, W., 7, 312–314, 317–318,
321, 333
Gold, S., 22
Goldenberg, H., 405, 423
Goldenberg, I., 405, 423
Goldfried, M., 428, 431
Goldman, R., 169, 171, 190, 206, 225
Goodman, R., 206
Goolishian, H., 369–370, 376, 410
Gottman, J., 411
Gould, W., 135
Granvold, D., 287
Greden, L., 23
Greenberg, L., 167–169, 171, 176, 190,
206, 430
Greenberger, D., 284, 286, 288–289
Griffith, J., 110
Gross, A., 244–245
Guterman, J., 373, 376, 378–379
Gutheil, T., 52
Guy, J., 34
Haberstroh, S., 353
Hackmann, A., 288
Haigh, E., 282, 284, 288
Haley, J., 424
Hammer, T., 343
Hanna, M., 286
Hanna, S., 409
Hardy, K., 416
Harper, R., 272–273
Harris, A., 79
Hawes, C., 108–109, 112
Hayes, J., 71–72
Hayes, S., 250–251, 255–256
Hays, D., 112
Hays, P., 298–299
Hazlett-Stevens, 245–246
Head, L., 244–245
Headley, J., 344, 348, 351
Healey, A., 126, 346
Hedges, L., 80–82
Hefferline, R., 206
Heidegger, M., 134–135
Heimberg, R., 263, 277, 279
Henry, J., 248–249, 256–257
Herbert, 250–251, 256
Herlihy, B., 23–24, 39, 42–43, 46, 49–50,
352–353, 362
Hermann, M., 23
Higginbotham, H., 258–259
Hilsenroth, M., 22
Hirsch, I., 69, 71, 73–75
Hoffman, E., 96
Hoffmann, S., 281, 287, 305
Hogan, T., 48–49, 192
Hollon, S., 263–264, 284–285, 287,
304
Horney, K., 271
Houts, A., 251, 255
Hoyt, M., 125, 372–374, 397, 434
Hubble, M., 18, 178, 192, 397, 430–431,
450–451
Hummel, A., 71–72
Imhof, L., 328–329
Ingram, R., 305
Iveson, C., 375–376, 379
Jacobs, L., 199, 206, 210, 214, 219,
224, 226
Jacobs, N., 277
Jacobson, E., 242
Jencius, M., 42, 52
Jennings, L., 19–20
Johnson, J., 100–103, 116, 126, 153
Johnson, R., 436–437
Johnson, W., 44, 46
Joiner, T., 48
Jones, J., 26
Jordan, J., 338, 343
Josselson, R., 138, 144, 146, 148–149,
152
Jung, C., 59, 77–79
Kabat-Zinn, J., 251, 253–254, 262
Kaplan, A., 338, 343
Karl, S., 47
Karpiak, C., 429
Kaschak, E., 342
Kazantzis, N., 287
Keefe, J., 69
Kefir, N., 102
Kemper, T., 48
Kendall, P., 287
Kernberg, O., 81–82
Kerr, M., 407
Kersh, B., 185
Kierkegaard, S., 134
Kim, R., 328–329
Kincade, E., 346, 349, 352–353
King, A., 339
Kirksey, K., 13, 87, 122, 156, 187, 223,
260, 302, 331, 357, 394, 455
Kirschenbaum, H., 164–165, 191
Klein, M., 81, 174
Knapp, S., 38
63727_Name Index_rev01.indd 482 21/09/15 3:52 PM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
N A m E I N d E x 483
Kocet, M., 23
Kohut, H., 80, 82
Kolden, G., 174
Koocher, G., 48–49, 192
Kress, V., 248–249, 256–257, 348, 353
Kriss, A., 75
Krug, O., 137, 139, 147, 153, 158, 169
Kuo, J., 252–253
Kuyken, W., 290
Lambert, M., 18, 430, 434, 451
Lambert, S., 405
Latner, J., 202
Lawson, D., 48
Lazarus, A., 250, 429
Lazarus, C., 250
Leahy, R., 287, 305
Ledley, D., 263, 277, 279
Lee, C., 44
Lee, M., 397
Leszez, M., 152
Levant, R., 48
Levensky, E., 185
Levenson, H., 83–84
Levitsky, A., 214
Levy, K., 82
Lewis, J., 409
Lichtanski, K., 139–140, 145
Linehan, M., 92, 250–253, 256
Lipchik, E., 398
Lisiecki, J., 116
Lister, K., 429
Lobovits, D., 381
Locke, D., 26
Lojk, L.,328–329
Lopez, S., 290
Luborsky, E., 67–70, 91–92
Ludgate, J., 288
Luepnitz, D., 410
Mackune-Karrer, B., 409, 415
Madigan, S., 386, 389, 391
Mahler, M., 81
Maisel, R., 381
Maniacci, M., 96, 105–106, 109, 116, 119,
125–126
Marbley, A., 346
Marecek, J., 348
Marlatt, G., 296
Martell, C., 237
Marx, B., 263, 277, 279
Maslow, A., 169, 171
Masterson, J., 82
Maurer, R., 213
May, R., 6, 131, 135, 142, 146, 148
McCarthy, K., 69
McCollum, E., 371
McCollum, V., 352–353
McDavis, R., 26
McDonald, A., 168
McElwain, B., 159
McGoldrick, M., 407, 416
McKenzie, W., 382, 387–390, 398
McWilliams, N., 59, 64, 67, 69, 71, 75,
79–80, 84, 91
Meichenbaum, D., 7, 270, 292–297, 305,
307
Melnick, J., 210–211
Messer, S., 83
Metcalf, L., 372, 380
Miller, J.B., 7, 338, 341, 343
Miller, M., 340, 344–345, 348–350, 352
Miller, S., 18, 178, 192, 397, 430–431,
450–452
Miller, T., 450
Miller, W., 182–183, 240, 436
Milliren, A., 102, 114
Miltenberger, R., 233, 239, 241–242
Minton, C., 47
Minuchin, S., 408, 424
Mitchell, S., 80, 82
Mooney, K., 289–291, 305, 307
Monk, G., 382–385–390, 397–398
Morgan, S., 254–255
Morgan, W., 254–255
Mosak, H., 105–106, 110–111, 125–126
Mozdzierz, G., 116
Muller, K., 252
Muran, J., 69
Murphy, J., 371–372, 375–377, 379–381,
398
Nagy, T., 42–43, 51
Nash, S., 340, 354
Neff, K., 254
Neukrug, E., 369, 371, 429, 434
Nevis, S., 210–211
Newbauer, J., 14
Newlon, B., 119–120
Newman, C., 287
Nichols, M., 409, 423
Nicoll, W., 108–109, 112, 114–115, 125
Nietzsche, F., 134
Niles, B., 251
Norcross, J., 18–22, 34, 48–49, 83, 176,
184, 192, 247, 264, 375, 428–431,
434, 442, 450
Nurius, P., 238, 243, 245, 250
Nutt, R., 338
Nylund, D., 390
O’Hanlon, W., 369 372, 375, 378, 383,
386–387, 391, 397
O’Reilly–Landry, M., 67–70, 91–92
Orlinsky, D., 21–22
Osborn, C., 238, 243, 245, 250
Pachankis, J., 428
Padesky, C., 7, 270, 280–281, 284,
286–291, 305, 307
Parsons, J., 343
Paul, G., 237
Peller, J., 373, 397
Peluso, P., 116
Perls, F., 7, 200, 206, 214, 217
Perls, L., 7, 210
Peterman, M., 287
Petry, S., 407
Pew, W., 98
Pfund, R., 429, 434
Pietrefesa, A., 251
Plummer, D., 220
Polster, E., 7, 198, 202, 204–205, 208–210,
212–213
Polster, M., 7, 198, 202, 204–205, 209–210,
212–213
Potter, C., 251
Powers, R., 110
Prata, G., 424
Pretzer, J., 287
Prochaska, J., 83, 184, 247, 264, 375,
429–430, 434, 450
Psychotherapy Networker, 429
Pusateri, C., 344, 348, 351
Raskin, N., 166
Ratner, H., 375–376, 379
Rego, S., 252
Reinecke, M., 270, 286–287
Reitzel, L., 48
Remer, P., 341, 344–351, 353–355, 363
Remley, T., 42–43, 46
Resnick, R., 199, 210, 214, 224
Rice, J., 338
Rice, R., 382, 385
Riskind, J., 287
Roberts, A., 406
Robertson, P., 126, 346
Robins, C., 252–253
Roemer, L., 233, 248, 251
Rogers, C., 7, 164–167, 170–171, 173,
175, 179–181, 185, 410
Rogers, N., 7, 164, 178–181, 191, 339
Rollnick, S., 182–183, 240
Ronnestad, M. 21
Rosenthal, M., 252–253
Rothblum, E., 338–339
Ruben, S., 139–140, 145
Rush, A., 282
Russell, D., 164–165
Russell, J., 136, 139–140, 147, 150, 159
Rutan, J., 70–71, 76–77, 79
Sackett-Maniacci, L., 105, 126
Safran, J., 75
63727_Name Index_rev01.indd 483 21/09/15 3:52 PM
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484 N A m E I N d E x
Salazar, G., 343
Salkovskis, P., 288
Salmon, P., 253–254
Sanchez, J., 26
Sartre, J., 136, 139
Satir, V., 7, 407–408, 410–411, 414
Sauer, A., 270, 286
Sawyer, A., 281, 287, 305
Scher, C., 305
Schmertz, S., 251
Schneider, K., 137, 139, 147, 149, 151,
153–154, 158, 169
Schore, A., 69
Schultz, D., 77–78, 99
Schultz, S., 77–78, 99
Schulz, F., 200–202, 209, 211–214
Schwartz, R., 409, 415
Sebold, J., 397
Seem, S., 346, 349, 352–353
Seeman, J., 165
Segal, Z., 251, 254–255, 305, 430
Segrin, C., 248
Seidel, J., 431, 450–451
Selvini Palazzolli, M., 424
Sephton, S., 253–254
Sgambati, R., 243
Shapiro, F., 247
Sharf, R., 84, 159
Sharp, J., 133–134, 151
Shaw, B., 282
Shay, J., 70–71, 76–77, 79
Sherman, R., 100
Shulman, B., 110
Siegel, R., 251, 256
Sinacore, A., 341
Skinner, B.F., 7, 232
Sklare, G., 381
Skovholt, T., 19–20
Smith, M., 450
Snyder, C., 290
Solomon, R., 247
Sonstegard, M., 97, 118–119, 406
Sparks, J., 452
Sperry, L., 19–20, 108, 116, 409
Spieglar, M., 233–234, 239, 241, 243,
245–247, 251, 256, 259, 264–265
Spotts-De Lazzer, A., 52
Stadler, H., 26
St. Clair, M., 79–81
Stebnicki, M., 34
Stern, D., 81
Stewart, M., 284, 287
Stiver, I., 338, 343
Stone, W., 70–71, 76–77, 79
Strentzsch, J., 343
Stricker, G., 429
Strosahl, K., 251, 255
Strumpfel, U., 225
Strunk, D., 284, 287
Strupp, H., 82
Sue, D., 26
Sue, D.W., 26
Surrey, J., 338, 343
Sweeney, T., 106
Tallman, K., 165, 173, 451
Tanaka-Matsumi, J., 258–259
Tausch, R., 165–167, 171, 177–178
Teasdale, J., 251, 254–255, 430
Terner, J., 98
Tharp, R., 249
Thomas, J., 390
Tillich, P., 131, 142
Tompkins, M., 285–286
Toporek, R., 26
Torres-Harding, S., 270, 286
Torres Rivera, E., 340, 354
Trepal, H., 343
Trepper, T., 371
Turner, L., 339
Uken, A., 397
Vaihinger, H., 100
VandeCreek, L., 38
Vonk, I., 281, 287, 305
Vontress, C., 141, 144, 149, 153, 159
Vujanovic, A., 251
Wade, A., 173, 451
Walker, L., 363
Walker, M., 343
Walsh, F., 407, 416
Walsh, R., 159
Walter, J., 373, 397
Walters, R., 232, 235
Wampold, B., 18–19, 178, 192, 430–431,
442, 451
Wang, C., 174
Warren, C., 83
Watson, D., 249
Watson, J., 171, 173, 176–177, 185,
190, 206
Watts, R., 96, 100, 105–106, 108–109,
111, 114–116, 119, 125–126
Weiner-Davis, M., 369, 372, 375,
378, 397
Weishaar, M., 270, 280, 282, 285–287,
307, 368
Wells, A., 288
Werner-Wilson, R., 339
West, J., 375, 409
Westra, H., 182
Wheeler, G., 199–200, 210–211
Wheeler, N., 42–43
White, B., 48
White, J., 281
White, M., 7, 369, 372, 381–382, 384,
386–389, 410, 414
Wiggins-Frame, M., 436
Williams, E., 339–340, 352, 354
Williams, J., 251, 254–255, 430
Williams, L., 405
Wilson, G., 233
Wilson, K., 251, 255
Winslade, J., 382–386, 389–390, 397
Wiseman, H., 21
Wolitzky, D., 59, 66–69, 71, 75–76, 82
Wolpe, J., 237
Worell, J., 341, 344–349, 353–354, 363
Worthington, E., 251, 436
Wubbolding, R., 7, 312–329, 334
Yalom, I., 6, 91, 131, 133, 138, 144, 146,
148–149, 152
Yeomans, F., 82
Yontef, G., 199–202, 206, 209–214, 219,
224, 226
Young, J., 436–437
Zahm, S., 224
Zimring, F., 165–167, 171, 177–178
Zinker, J., 202, 206, 212, 226
Zur, O., 50
63727_Name Index_rev01.indd 484 21/09/15 3:52 PM
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A N I N T E G R AT I V E P E R S P E C T I V E 485 Subject Index
A-B-C framework, 273
ABC model, 238
Acceptance, 175, 251
Acceptance and commitment therapy,
255–256
Acceptance-based approaches, 250–256
Accommodation, 209
Accurate empathic understanding, 170,
175–176
Action plan, 288
Action, planning and, 324–326
Action stage, 184
Actualizing tendency, 170
Adlerian brief therapy, 108
Adlerian therapy, 95–128
application, 108–119
applied to the case of Gwen, 122–124
applied to the case of Stan, 121–122
client’s experience, 106–107
contributions, 125–126
key concepts, 98–104
limitations and criticisms, 126
multicultural perspective, 119–121
relationship between therapist and
client, 107–108
shortcomings, 120–121
strengths, 119–120
therapeutic goals, 104–105
therapeutic process, 104–108
therapeutic techniques and
procedures, 108–119
therapist’s function and role, 105–106
Adolescence, 65
Advice, 32
Aloneness, 142
Ambiguity, 30–31
Anal stage, 63, 65
Analytic framework, maintaining the, 73
Analytical psychology, 77
Anima, 78
Animus, 78
Antecedent event, 238
Anxiety, 28, 61, 144–145
Anxiety, existential, 144
Anxiety, neurotic, 145
Anxiety, normal, 145
Application to group counseling
Adlerian therapy, 118–119
behavior therapy, 256–258
choice theory/reality therapy, 326–327
existential therapy, 151–153
feminist therapy, 352
Gestalt therapy, 218–220
integrative approach, 444–445
narrative therapy, 390
person-centered therapy, 179–180
postmodern approaches,
psychoanalytic therapy, 76–77
rational emotive behavior therapy, 279
solution-focused brief therapy,
380–381
Approaches, theoretical
Adlerian therapy, 95–128
behavior therapy, 231–268
choice theory/reality therapy,
311–336
cognitive behavior therapy, 269–310
existential therapy, 129–162
family systems therapy, 403–425
feminist therapy, 337–366
Gestalt therapy, 197–229
integrative perspective, 427–460
person-centered therapy, 163–195
postmodern approaches, 367–401
psychoanalytic therapy, 57–93
social constructionism, 368–370
solution-focused brief therapy,
371–381
Arbitrary inferences, 283
Archetypes, 78
Aspirational ethics, 38
Assertiveness training, 351–352
Assessment, 45, 177–178, 237, 348,
411–414
Assessment, functional, 237
Assimilation, 209
Assimilative integration, 430
Authenticity, 140
Automatic thoughts, 288
Autonomy versus shame and doubt, 65
Awareness, 206
Awareness, resistance to, 213
Basic philosophies, 432
Behavior therapy, 231–268
application, 240–258
applied to the case of Gwen, 260–262
applied to the case of Stan, 259–260
areas of development, 234–236
basic characteristics and assumptions,
236–237
client’s experience, 239–240
contributions, 263–264
historical background, 233–234
key concepts, 236–237
limitations and criticisms, 264–265
multicultural perspective, 258–259
relationship between therapist and
client, 240
shortcomings, 259
strengths, 258–259
therapeutic goals, 238
therapeutic process, 238–240
therapeutic techniques and
procedures, 240–258
therapist’s function and role, 238–239
Behavioral analysis, 238
Behavioral assessment interview, 238
Beliefs and attitudes, 26
Belonging, 102
Belonging power, love and, 314
Bibliotherapy, 276–277, 351
Birth order, 103
Blank-screen approach, 67
Blocks to energy, 205
Borderline personality disorder, 82
Boundary crossing, 51
Boundary violation, 52
Brief psychodynamic therapy, 83
Change, 115, 184, 321–322, 415
Characteristics, of effective counselors,
19–20
Choice theory/reality therapy, 311–336
application, 320–327
applied to the case of Gwen, 331–332
applied to the case of Stan, 329–330
client’s experience, 319
contributions, 332–333
key concepts, 314–318
limitations and criticisms, 333–334
multicultural perspective, 327–329
relationship between therapist and
client, 319–320
shortcomings, 329
strengths, 327–328
therapeutic goals, 318
therapeutic process, 318–320
therapeutic techniques and
procedures, 320–327
therapist’s function and role, 318–320
Classical conditioning, 235
Classical psychoanalysis, 64, 68
Client-centered therapy, 166
Codes, ethics, 39–40
Cognitive behavior modification,
293–298
contributions, 305–306
limitations and criticisms, 307
485
63727_Subject Index_rev02.indd 485 30/09/15 9:38 AM
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
486 S u b j E C T I N d E x
Cognitive behavior therapy, 236,
269–310
applied to the case of Gwen, 302–303
applied to the case of Stan, 300–301
cognitive therapy, 281–288
contributions, 304–306
limitations and criticisms, 306–307
multicultural perspective, 298–299
rational emotive behavior therapy,
270–280
shortcomings, 298–299
strengths, 298
strengths-based cognitive behavior
therapy, 289–292
Cognitive homework, 276
Cognitive methods, 276–277
Cognitive model, generic, 282
Cognitive narrative approach, 297–298
Cognitive therapy, 280–288
applications, 287–288
basic principles, 284–285
client-therapist relationship, 286–287
contributions, 304–305
generic cognitive model, 282–284
limitations and criticisms, 306–307
Cognitive triad, negative, 282
Collaborative empiricism, 285
Collective unconscious, 78
Commitment, 140
Commitment, lack of, 30
Common factors approach, 430
Community feeling, 101–102
Compensation, 63
Concern-based ethics, 38
Confidentiality, 42–43
Confluence, 203
Confrontation, 214
Congruence, 170, 174–175
Consciousness, 60–61
Consequences, 238
Contact, 202–203
Contact, resistances to, 202–203, 213
Contemplation stage, 184
Contemporary psychoanalysis, 64
Contemporary relational Gestalt
therapy, 200
Contextual factors, 19
Counseling environment, 321
Countertransference, 31, 71
Courage, 142
Crisis, 64
Crisis intervention, 178–179
Culture, 25, 27–28
Cycle of counseling, 320
Death, 145–146
Death instincts, 59
Decision making, ethical, 39–41
Deconstruction, 386–388
Deflection, 203
Demands, 30
Denial, 62
Despair, integrity versus, 66
Development, stages of, 80–82
Diagnosis, 45, 348
Dialectical behavior therapy, 251–253
Dialogue, 209
Dichotomous thinking, 284
Direction and doing, 323
Displacement, 62
Disputing irrational beliefs, 276
Doing, direction and, 323
Dream analysis, 74
Dream work, 74, 217–218
Dual relationships, 49–52
Early childhood, 65
Early recollections, 106, 111–112
Egalitarian relationship, 344
Ego, 60
Ego-defense mechanism, 61–62
Ego psychology, 64, 79
Emotion-focused therapy, 167–168
Emotional disturbance, view of, 272–273
Emotive techniques, 277–278
Empathy, 175
Empowerment, 349
Empty-chair technique, 215
Encouragement, 114
Energy, 205
Energy, blocks to, 205
Engendered lives, 342
Ethical decision making, 39–41
Ethical decisions, 38
Ethical issues, 37–56
Ethical issues, assessment process, 45–47
Ethical issues, multicultural perspective,
43–45
Ethical obligation, 25
Ethics codes, 39–40
Evidence-based practice, 48–49
Exaggeration exercise, 217
Exception questions, 377–378
Exceptions, 377
Exercises, 211
Existential analysis, 135
Existential anxiety, 144
Existential guilt, 140
Existential neurosis, 144
Existential therapy, 129–162
application, 149–153
applied to the case of Gwen, 156–157
applied to the case of Stan, 155
client’s experience, 147–148
contributions, 158–159
key concepts, 137–146
key figures, 136–137
limitations and criticisms, 159
multicultural perspective, 153–154
relationship between therapist and
client, 148–149
shortcomings, 154
strengths, 153–154
therapeutic goals, 146–147
therapeutic process, 146–149
therapeutic techniques and
procedures, 149–153
therapist’s function and role, 147
Existential tradition, 137–138
Existential vacuum, 144
Existentialism, 168–169
Experiments, 211
Exposure therapies, 245
Expressive arts therapy, 180–182
Externalization, 386–388
Externalizing conversations, 387
Externally motivated, 314
Extinction, 241
Eye movement desensitization and
reprocessing (EMDR), 247
Family constellation, 106, 110–111
Family systems perspective, 404–405
Family systems therapy, 403–425
applied to the case of Gwen, 420–422
applied to the case of Stan, 417–420
basic assumption, 422
contributions, 423
development of, 406–407
focus, 422
goals and values, 422
human validation process model, 407
limitations and criticisms, 423–424
multicultural perspective, 415–417
multigenerational, 407
multilayered process, 409–415
postmodern perspectives, 409
shortcomings, 416–417
strengths, 415–416
structural-strategic, 408
techniques, 423
therapeutic relationship, 410
Faulty assumptions, 104
Fear-based ethics, 38
Feedback, therapist, 379
Feedback-informed treatment, 451
Feeling, staying with, 217
Feelings, 176
Feminist counseling, 339
Feminist perspective, 339
Feminist psychotherapy, 339
Feminist therapy, 337–366
application, 348–353
applied to the case of Gwen, 357–360
63727_Subject Index_rev02.indd 486 30/09/15 9:38 AM
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
S u b j E C T I N d E x 487
applied to the case of Stan, 355–357
client’s experience, 347
contributions, 361–363
history and development, 340–341
key concepts, 341–345
limitations and criticisms, 363
multicultural and social justice
perspective, 354–355
principles of, 343–345
relationship between therapist and
client, 347
shortcomings, 355
strengths, 354
techniques and strategies, 349–354
therapeutic goals, 345–346
therapeutic process, 345–347
therapeutic techniques and
procedures, 348–353
therapist’s function and role,
346–347
Fictional finalism, 100
Field, 199
Field theory, 201
Figure, 201
Figure-formation process, 201–202, 212
Flexible-multicultural perspective, 341
Flooding, 245–246
Formula first session task, 378
Free association, 68, 73
Freedom, 139–141, 314
Friendship, 102
Fun, 314
Functional assessment, 238
Future projection technique, 215–216
Gender-fair approaches, 341
Gender-role, 350
Gender-role intervention, 350–351
Generativity versus stagnation, 66
Generic cognitive model, 282
Genital stage, 65–66
Genuineness, 174–175
Gestalt therapy, 197–229
application, 211–220
applied to the case of Gwen, 223–224
applied to the case of Stan, 221–222
client’s experience, 209–210
contributions, 225
interventions, 214–218
key concepts, 200–205
limitations and criticisms, 226
multicultural perspective, 220–221
relationship between therapist and
client, 210–211
shortcomings, 221
strengths, 220–221
therapeutic goals, 206
therapeutic process, 206–211
therapeutic techniques and
procedures, 211–220
therapist’s function and role, 206–209
Goals, 438
Adlerian therapy, 104–105
behavior therapy, 238
choice theory/reality therapy, 318
existential therapy, 146–147
family systems therapy, 422
feminist therapy, 345–346
Gestalt therapy, 206
integrative perspective, 437–439
narrative therapy, 384
person-centered therapy, 171
psychoanalytic therapy, 66–67
rational emotive behavior therapy,
273–274
solution-focused brief therapy, 375
Ground, 201
Group work, 352–353
Guilt, initiative versus, 65
Gwen, case of
Adlerian therapy, 122–124
behavior therapy, 260–262
choice theory/reality therapy, 331–332
cognitive behavior therapy, 302–303
existential therapy, 156–157
family systems therapy, 420–422
feminist therapy, 357–360
Gestalt therapy, 223–224
integrative approach, 455–456
person-centered therapy, 187–189
postmodern approaches, 394–396
psychoanalytic therapy, 87–88
Here-and-now, 137
Hierarchy of needs, 170
Holism, 201
Holistic concept, 100
Homework, cognitive, 276
Human nature, view of
Adlerian therapy, 98–99
choice theory/reality therapy, 314–315
existential therapy, 137–138
Gestalt therapy, 200–201
person-centered therapy, 170–171
psychoanalytic therapy, 59
Human personality, 99–101
Human validation process model, 407
Humanism, 168–169
Humanistic philosophy, 170
Humanistic psychology, 169–170
Humor, 31–32, 278
Hypothesizing, 414–415
Id, 60
Id psychology, 64
Identification, 63
Identity, 141–143
Identity versus role confusion, 65
Immediacy, 177
Impasse, 205
Inauthenticity, 139
Individual psychology, 99
Individuation, 78
Industry versus inferiority, 65
Infancy, 65
Inferiority feelings, 99
Inferiority, industry versus, 65
Informed consent, 41–42
Initiative versus guilt, 65
Insight, 113
Instincts, death, 59
Instincts, life, 59
Integration, 113
Integrative perspective, 427–460
advantages of psychotherapy
integration, 431
applied to the case of Gwen, 455–456
applied to the case of Stan, 452–455
challenge of developing, 431–433
client’s experience, 440
integration of multicultural issues,
435
integration of spirituality and religion,
435–437
movement toward psychotherapy
integration, 428–437
relationship between therapist and
client, 440–442
techniques and evaluation, 443–452
therapeutic goals, 437–439
therapeutic process, 437–442
therapist’s function and role, 439
Integrity versus despair, 66
Interactionist, 341
Internal dialogue, 294
Internal dialogue exercise, 215
Interpretation, 74, 113
Intimacy versus isolation, 66
Introjection, 63, 202
In vivo exposure, 245–246
In vivo flooding, 246
Isolation, intimacy versus, 66
Key concepts, 433–434
Adlerian therapy, 98–104
behavior therapy, 236–237
choice theory/reality therapy,
314–318
existential therapy, 137–146
family systems therapy, 410–415
feminist therapy, 341–345
Gestalt therapy, 200–205
narrative therapy, 382–383
person-centered therapy, 170–171
63727_Subject Index_rev02.indd 487 30/09/15 9:38 AM
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
488 S u b j E C T I N d E x
Key concepts (continued )
psychoanalytic therapy, 59–66
rational emotive behavior therapy,
272–273
solution-focused brief therapy, 371–374
Kindness, 254
Labeling, 283
Language, 207, 277, 370
Latency stage, 65
Latent content, 74
Later life, 66
Libido, 59
Life-changing psychotherapy, 136
Life instincts, 59
Life-span perspective, 341
Lifestyle, 101
Lifestyle assessment, 106
Life tasks, 102–103
Listening, 382
Logotherapy, 144
Love and belonging power, 314
Magnification, 283
Maintaining the analytic framework, 73
Maintenance stage, 184
Making the rounds, 216
Mandatory ethics, 38
Manifest content, 74
Meaning, search for, 143–144
Meaning, sharing, 414–415
Meaninglessness, 144
Middle age, 66
Middle child, 104
Mindfulness, 250–256
Mindfulness-based cognitive therapy,
254–255, 430
Mindfulness-based stress reduction,
253–254
Minimization, 283
Minor psychotherapy, 108
Miracle question, 378
Mislabeling, 283
Mistaken goals, 104
Mistrust, trust versus, 65
Moral anxiety, 61
Motivational Interviewing, 182–184
Multicultural counseling, 25–28
Multigenerational family therapy, 407
Multimodal therapy, 250
Multiple relationships, 49–52
Narrative therapy, 382–390
application, 386–390
focus of, 382
key concepts, 382–383
therapeutic process, 383–384
therapeutic relationship, 385
therapeutic techniques and
procedures, 386–390
therapist’s function and role,
384–385
therapy goals, 384
Narcissistic personality, 81
Needs, hierarchy of, 170
Negative cognitive triad, 282
Negative reinforcement, 241
Neurotic anxiety, 61, 145
Nonbeing, 145–146
Nondirective counseling, 166
Nonprofessional relationships, 49
Normal anxiety, 145
Normal infantile autism, 81
Not-knowing position, 370, 376, 396
Now, the, 204
Objective interview, 110
Object-relations theory, 79–84
Oldest child, 103
Only child, 104
Operant conditioning, 235
Operant conditioning techniques,
241–242
Oral stage, 63, 65
Organismic self-regulation, 202
Outcome rating scale, 451
Overgeneralization, 283
Paradoxical theory of change, 201
Perfectionism, 29
Person-centered approach, 167
Person-centered therapy, 163–195
application, 176–180
applied to the case of Gwen, 187–189
applied to the case of Stan, 186–187
client’s experience, 172–173
contributions, 190–191
development of the approach, 166–167
key concepts, 170–171
limitations and criticisms, 192–193
multicultural perspective, 184–186
relationship between therapist and
client, 173–176
shortcomings, 185–186
strengths, 184–185
therapeutic goals, 171
therapeutic process, 171–176
therapeutic techniques and
procedures, 176–180
therapist’s function and role, 171–172
Persona, 78
Personal characteristics, of effective
counselors, 19–20
Personal therapy, 20–22
Personality, development of, 63–66,
77–79
Personality, structure of, 59–61
Personalization, 283
Phallic stage, 63, 65
Phenomenological, 99
Phenomenological inquiry, 204
Picture album, 315
Planning and action, 324–326
Pleasure principle, 60
Positive ethics, 38
Positive orientation, 372
Positive psychology, 169, 372
Positive reinforcement, 241
Postmodern approaches, 367–410
applied to the case of Gwen, 394–396
applied to the case of Stan, 392–394
contributions, 397–398
limitations and criticisms, 398
multicultural perspective, 390–391
narrative therapy, 382–390
shortcomings, 391–392
social constructionism, 368–370
solution-focused brief therapy,
371–381
strengths, 390–391
Power analysis, 351
Precontemplation stage, 184
Preparation stage, 184
Preschool age, 65
Presence, 177
Present, 317
Pretherapy change, 377
Private logic, 106
Privileged communication, 42
Professional burnout, 34
Professional role, 33–34
Progressive muscle relaxation, 242–243
Projection, 62, 203
Psychoanalytic therapy, 57–93
application, 72–77
application to group counseling,
76–77
applied to the case of Gwen, 87–88
applied to the case of Stan, 85–87
client’s experience, 68–69
contributions, 89–91
counseling implications, 64
key concepts, 59–66
limitations and criticisms, 91–92
multicultural perspective, 84–85
relationship between therapist and
client, 69–72
shortcomings, 85
strengths, 84–85
therapeutic goals, 66–67
therapeutic process, 66–72
therapeutic techniques and
procedures, 72–77
therapist’s function and role, 67–68
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S u b j E C T I N d E x 489
Psychodynamic therapy, 68
Psychoeducational methods, 277
Psychological investigation, 104
Psychosexual stages, 63, 65–66
Psychosocial stages, 64–66
Psychotherapy integration, 429
Punishment, 242
Punishment, negative, 242
Punishment, positive, 242
Quality world, 315
Question, miracle, 378
Questions, 386
Questions, exception, 377–378
Questions, scaling, 378
Rational emotive behavior therapy
(REBT), 270–279
application, 275–279
behavioral techniques, 279
client’s experience, 274–275
cognitive methods, 276–277
contributions, 304
emotive techniques, 277–278
key concepts, 272–273
limitations and criticisms, 306
relationship between therapist and
client, 275
therapeutic goals, 273–274
therapeutic process, 273–275
therapeutic techniques and
procedures, 275–279
therapist’s function and role, 274
view of emotional disturbance,
272–273
Rational emotive imagery, 277–278
Rationalization, 62
Reaction formation, 62
Reality, 99
Reality anxiety, 61
Reality therapy/choice theory, 311–336
application, 320–327
applied to the case of Gwen, 331–332
applied to the case of Stan, 329–330
client’s experience, 319
contributions, 332–333
key concepts, 314–318
limitations and criticisms, 333–334
multicultural perspective, 327–329
relationship between therapist and
client, 319–320
shortcomings, 329
strengths, 327–328
therapeutic goals, 318
therapeutic process, 318–320
therapeutic techniques and
procedures, 320–327
therapist’s function and role, 318–320
Reeducation, 113–117
Reframing, 352
Regression, 63
Rehearsal exercise, 216–217
Reinforcement, negative, 241
Reinforcement, positive, 241
Relabeling, 352
Relapse prevention, 296
Relatedness, 142–143
Relational-cultural theory, 342–343
Relational model, 80
Relational psychoanalysis, 79–84
Relationship, 410–411
Reorientation, 113–117
Repression, 62
Research, 191
Resistance, 75, 136, 213
Resistances to contact, 202–203
Responsibility, 32, 139–141, 316–317
Restricted existence, 147
Retroflection, 203
Reversal exercise, 216
Role confusion, identity versus, 65
Role of stories, 382
Role playing, 278
Scaling questions, 378
Schema, 288
School age, 65
Second child, 103–104
Selective abstraction, 283
Self-awareness, 138–139
Self-care, 34
Self-compassion, 254
Self-directed behavior, 248–250
Self-disclosure, 28–29, 349–350
Self-efficacy, 235
Self-evaluation, 322–323
Self-instructional training, 293
Self-management programs, 248–250
Self-observation, 294
Self psychology, 79–84
Self-understanding, 113
Self-worth, 102
Separation–individuation, 81
Session rating scale, 451
Shadow, 78
Shame and doubt, autonomy versus, 65
Shame attacking exercises, 278
Sibling relationships, 103–104
Significance, 100–101
Silence, 30
Skills and intervention strategies,
26–27
Social action, 352
Social constructionism, 368–370
Social identity analysis, 350
Social interest, 101–102
Social learning approach, 235
Social media, 52
Social skills training, 248
Solution-focused brief therapy, 371–381
application, 377–381
basic assumptions, 373
characteristics, 373–374
key concepts, 371–374
therapeutic goals, 375
therapeutic process, 374–375
therapeutic relationship, 376–377
therapeutic techniques and
procedures, 377–381
therapist feedback, 379
therapist’s function and role, 375–376
unique focus, 371–372
Stages of development, 80–82
Stagnation, generativity versus, 66
Stan, case of
Adlerian therapy, 121–122
behavior therapy, 259–260
choice theory/reality therapy,
329–330
cognitive behavior therapy, 300–301
existential therapy, 155
family systems therapy, 417–420
feminist therapy, 355–357
Gestalt therapy, 221–222
integrative approach, 452–455
person-centered therapy, 186–187
postmodern approaches, 392–394
psychoanalytic therapy, 85–87
Stories, role of, 382
Strengths-based cognitive behavioral
therapy, 289–292
applications, 291–292
basic principles, 290
client-therapist relationship, 291
contributions, 305
limitations and criticisms, 307
Stress inoculation training, 294–297
Structural family therapy, 408
Structural-strategic approaches, 408
Student-centered teaching, 167
Subjective interview, 109
Sublimation, 63
Suggesting tasks, 379
Summary, 113
Superego, 60
Superiority, 100–101
Survival, 314
Symbiosis, 81
Syncretism, 428–429
Systematic desensitization, 243–245
Technical integration, 429
Techniques, therapeutic, 33
Terminating, 379–380
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490 S u b j E C T I N d E x
Theoretical approaches
Adlerian therapy, 95–128
behavior therapy, 231–268
choice theory/reality therapy, 311–336
cognitive behavior therapy, 269–310
existential therapy, 129–162
family systems therapy, 403–425
feminist therapy, 337–366
Gestalt therapy, 197–229
integrative perspective, 427–460
narrative therapy, 382–390
person-centered therapy, 163–195
postmodern approaches, 367–401
psychoanalytic therapy, 57–93
social constructionism, 368–370
solution-focused brief therapy, 371–381
Theoretical integration, 429
Therapeutic core conditions, 173
Therapeutic techniques, 33
Therapist feedback, 379
Therapy methods, 19
Therapy, personal, 20–22
Therapy relationship, 19
Thought records, 288
Total behavior, 315
Transference, 70, 75–76, 317
Transference relationship, 67
Trust versus mistrust, 65
Unconditional positive regard,
170, 175
Unconscious, 60–61
Unfinished business, 205
Value imposition, 23
Values, 22–24
Wants, 322–323
WDEP system, 322–326
Working-through process, 70
Young adulthood, 66
Youngest child, 104
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About the Author
Contents
Preface to Tenth Edition
Ch 1: Introduction and Overview��������������������������������������
Learning Objectives
Introduction�������������������
Where I Stand��������������������
Suggestions for Using the Book�������������������������������������
Overview of the Theory Chapters��������������������������������������
Introduction to the Case of Stan���������������������������������������
Introduction to the Case of Gwen���������������������������������������
Ch 2: The Counselor: Person and Professional���������������������������������������������������
Learning Objectives
Introduction�������������������
The Counselor as a Therapeutic Person��������������������������������������������
Personal Therapy for the Counselor�����������������������������������������
The Counselor’s Values and the Therapeutic Process���������������������������������������������������������
Becoming an Effective Multicultural Counselor����������������������������������������������������
Issues Faced by Beginning Therapists�������������������������������������������
Summary��������������
Ch 3: Ethical Issues in Counseling Practice��������������������������������������������������
Learning Objectives
Introduction�������������������
Putting Clients’ Needs before Your Own���������������������������������������������
Ethical Decision Making������������������������������
The Right of Informed Consent������������������������������������
Dimensions of Confidentiality������������������������������������
Ethical Issues from a Multicultural Perspective������������������������������������������������������
Ethical Issues in the Assessment Process�����������������������������������������������
Ethical Aspects of Evidence-Based Practice�������������������������������������������������
Managing Multiple Relationships in Counseling Practice�������������������������������������������������������������
Becoming an Ethical Counselor������������������������������������
Summary��������������
Where to Go from Here����������������������������
Recommended Supplementary Readings for Part 1����������������������������������������������������
Ch 4: Psychoanalytic Therapy�����������������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Jung’s Perspective on the Development of Personality�����������������������������������������������������������
Contemporary Trends: Object-Relations Theory, Self Psychology, and Relational Psychoanalysis���������������������������������������������������������������������������������������������������
Psychoanalytic Therapy from a Multicultural Perspective��������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 5: Adlerian Therapy�����������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Adlerian Therapy from a Multicultural Perspective��������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 6: Existential Therapy��������������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Existential Therapy from a Multicultural Perspective�����������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 7: Person-Centered Therapy������������������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Person-Centered Expressive Arts Therapy����������������������������������������������
Motivational Interviewing��������������������������������
Person-Centered Therapy from a Multicultural Perspective���������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 8: Gestalt Therapy����������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures
Gestalt Therapy from a Multicultural Perspective�������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 9: Behavior Therapy�����������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Behavior Therapy from a Multicultural Perspective��������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 10: Cognitive Behavior Therapy����������������������������������������
Learning Objectives
Introduction�������������������
Albert Ellis’s Rational Emotive Behavior Therapy�������������������������������������������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Aaron Beck’s Cognitive Therapy�������������������������������������
Christine Padesky and Kathleen Mooney’s Strengths-Based Cognitive Behavioral Therapy�������������������������������������������������������������������������������������������
Donald Meichenbaum’s Cognitive Behavior Modification�����������������������������������������������������������
Cognitive Behavior Therapy from a Multicultural Perspective������������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 11: Choice Theory/Reality Therapy�������������������������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Choice Theory/Reality Therapy from a Multicultural Perspective���������������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 12: Feminist Therapy������������������������������
Learning Objectives
Introduction�������������������
Key Concepts�������������������
The Therapeutic Process������������������������������
Application: Therapeutic Techniques and Procedures���������������������������������������������������������
Feminist Therapy from a Multicultural and Social Justice Perspective���������������������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 13: Postmodern Approaches�����������������������������������
Learning Objectives
Some Contemporary Founders of Postmodern Therapies���������������������������������������������������������
Introduction to Social Constructionism���������������������������������������������
Solution-Focused Brief Therapy�������������������������������������
Narrative Therapy������������������������
Postmodern Approaches from a Multicultural Perspective�������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 14: Family Systems Therapy������������������������������������
Learning Objectives
Introduction�������������������
Development of Family Systems Therapy��������������������������������������������
A Multilayered Process of Family Therapy�����������������������������������������������
Family Systems Therapy from a Multicultural Perspective��������������������������������������������������������������
Summary and Evaluation�����������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
Ch 15: An Integrative Perspective����������������������������������������
Learning Objectives
Introduction�������������������
The Movement toward Psychotherapy Integration����������������������������������������������������
Issues Related to the Therapeutic Process������������������������������������������������
The Place of Techniques and Evaluation in Counseling�����������������������������������������������������������
Summary��������������
Concluding Comments��������������������������
Self-Reflection and Discussion Questions�����������������������������������������������
Where to Go from Here����������������������������
Recommended Supplementary Readings�����������������������������������������
References and Suggested Readings����������������������������������������
Name Index�����������������
Subject Index
2015-12-15T20:54:40+0000
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